[Deforming endonasal mass during pregnancy]

This article presents the case of a 33-year-old woman who consulted the authors' ENT clinic in the 39th week of pregnancy with recurrent epistaxis. A livid endonasal mass was found on the left side, subtotally displacing the nose and leading to deformation of the external nose. External biopsy provided no indications of malignancy. Postpartum CT of the paranasal sinuses revealed a mass destroying the cartilaginous nasal septum. Endoscopic resection of the finding was performed with preservation of the clinically sound nasal septal cartilage. Histopathological examination revealed a capillary hemangioma, which was classified as granuloma gravidarum due to its occurrence during pregnancy.

Reconstruction of nasal tip support in primary, open approach septorhinoplasty : A retrospective analysis between the tongue-in-groove technique and the columellar strut

The reconstruction of the nasal tip support is one of the most essential issues in septorhinoplasty. A comparison of the results after using the tongue-in-groove technique and the columellar strut technique was the target of this study. Thirty-three patients who underwent a primary, open approach septorhinoplasty using the above-mentioned techniques were retrospectively analyzed. The gain in tip rotation postoperatively, the sensitivity and the rigidity of the nasal tip and the aesthetic outcome after surgery were examined and evaluated. Both techniques led to an increase in nasal tip rotation postoperatively. The gain in rotation was higher in patients, treated with the tongue-in-groove technique (p = 0.0052). The sensitivity of the tip region in the tongue-in-groove group of patients was significantly lower than that in the columellar strut group of patients (p = 0.0424). Both techniques led to high percentages of tip rigidity after surgery with satisfactory aesthetic results though. The tongue-in-groove technique and the columellar strut technique are both reliable techniques for reconstructing the nasal tip support and correcting a droopy tip. Although the tongue-in-groove technique might result in a more significant increase in tip rotation, it leads to less sensitivity in the tip region.

[Septum necrosis following CPAP treatment of preterm infant]

This case describes the complications of intensive respiratory support in a preterm infant. During two months of rigorous nasal continuous positive airway pressure (CPAP) therapy with intermittent use of CPAP-mask and -prongs, an ulcer in the nasal mucus membrane developed into septum necrosis. Preterm infants are in high risk of needing long-term respiratory support, why it is important to bear in mind that binasal CPAP-prongs have proved to be more effective than mononasal therapy, and that CPAP-prongs and -mask have different sites of injury.

[Clinical anatomic study of Pitanguy ligament of the nose]

OBJECTIVE

To observe the origins and insertions of Pitanguy ligament,in order to find the anatomically theoretical basis for the treatment of nasal deformity such as drooping nose, short columella, gingival show.

METHODS

15 cadaveric heads fixed by 10% formalin were used. 12 specimens underwent nasal anatomic study. The skin was incised, along the nasal midline to expose the Pitanguy ligament. The origin of Pitanguy ligament and its relationship with surrounding tissue were studied. Then the Pitanguy ligament was taken out for HE staining. Longitudinal section along the ligament was observed. 3 specimens underwent harvesting of full-thickness nasal tissue from skin to periosteal membrane. Then the samples were used for HE staining to show histologic study of ligament at horizontal section.

RESULTS

Pitanguy ligament originates in the midline of lower third of the nasal superficial musculoaponeurotic system, extends down to the tip along the midline of the nasal dorsum and then turns backwards at the nasal tip, and runs between the medial crura of the lower lateral cartilages, inserts into the base of columella. Its muscle is connected with the orbicularis oris muscle and the depressor septi nasi muscle. HE staining showed the ligament consists of fibrous connective tissue, muscle tissue and other ingredients, but without cartilage.

CONCLUSIONS

Pitanguy ligament exists with complex histological composition, so its name is still controversial. Because it has multiple connection with the orbicularis oris muscle and the depressor septi nasi muscle, so cutting or shortened the Pitanguy ligament can treat deformity of nose and lip by adjustment of nasolabial angles and the nasal length.

Severe saddle nose deformity reconstructed with rib cartilage

Augmenting the nasal dorsum is often a difficult task, because of the irregularities that might be visible under the thin dorsal nasal skin. Saddle noses are especially difficult to correct because of the need to provide strong structural support to the nose while at the same time achieving an aesthetic dorsum. Stable reconstruction of the cartilaginous septum is the critical challenge in the operative treatment of such deformities with both functional and morphological implications. Treatment depends on the degree of saddling. Autologous cartilage is widely recognized to be the standard against which other materials must be judged. It is the most acceptable and reliable long-term graft. We present a case of unusually severe posttraumatic saddle nose resolved with a single rather large costal cartilaginous graft and a columellar strut. Classic extended spreader grafts could not be used due to the lack of bony and cartilaginous support of the nasal pyramid and, thus, no possibility of stabilization. A normal nasal dorsum, as well as breathing improvement, were achieved and the patient was extremely satisfied with the result. We had no complications except a slight asymmetry of the nostrils. Graft resorbtion or displacement was not observed on the 14-months follow-up.

Nasal tip angiolipoma: the "Pinocchio" nasal deformity

Angiolipoma is a rare, benign variant of lipoma; its distinctive feature is its prominent vascularity. It presents as a subcutaneous nodule of white adipose tissue; pain, which may be exacerbated by pressure, is the chief symptom. The anatomic distribution predominantly involves the trunk and extremities. Because of the rarity of this condition in otorhinolaryngology, our understanding of its diagnosis, treatment, and follow-up is limited. Microscopically, two different histopathologic forms of angiolipomas exist: circumscribed and infiltrating. The diagnosis of angiolipoma can be aided by ultrasound, computed tomography, or magnetic resonance imaging. Surgical excision remains the treatment of choice. Sites of previously reported otolaryngologic cases include the cheek, palate, mandible, nasal septum, and cervical area. We describe what we believe to be the second case of a nasal tip angiolipoma in a 78-year-old woman complaining of progressive aesthetic deformity.

Nasal ala reconstruction with a crus helix composite graft: a stepladder approach

BACKGROUND

Defects of the nasal ala present a complex reconstructive challenge. Composite grafts comprise all layers required to successfully reconstruct these full thickness deformities making them the ideal reconstructive method, yet they are usually avoided because of unjustified disreputable failure rates.

OBJECTIVE

The authors introduce a stepladder approach for alar reconstruction with a crus of helix composite graft according to the severity and complexity of the defect.

METHODS

Data from 25 patients who underwent correction of full thickness alar defects with composite grafts was collected and reviewed.

RESULTS

There were no complete graft failures in any of the cases. Ten patients (40%) had partial graft necrosis ranging from 5 to 50% (average 18%); two of them (20%) were heavy smokers.

CONCLUSIONS

Composite grafts should be considered for reconstruction of full thickness nasal ala defects, given the correct surgical technique is implemented.

[It's normal--structural and functional variations of nose and paranasal sinuses]

Many nasal symptoms can be caused by normal variation in nasal structure or functioning. External nasal deformity necessitates further examinations only when remarkable or causing nasal blockage. Septal deformities are often seen also in patients without any symptoms. The size of nasal turbinates and the number or size of paranasal sinuses may vary causing sometimes problems in the interpretation of radiological imaging. Abnormal radiological findings can be detected also in asymptomatic patients, most commonly mucosal thickening and cysts of paranasal sinuses. Meticulous clinical examination including decongestation of nasal mucosa is a key for sorting out meaningful connection between symptoms and findings.

[The influence of the defects and deformities in the intranasal septum on the main functions of the nose (preliminary report)]

AIM OF THE STUDY

to estimate the influence of the defects and deformities in the intranasal septum on the main functions of the nose and therefore on the state of the upper respiratory tract and the ears.

METHODS

A total of 180 patients suffering deformation of the nasal septum were available for the examination. The study included the evaluation of breath characteristics, excretory and inspiratory functions of the nose compared with control with the use of the conventional methods including rhinometry.

RESULTS

The patients presenting with the defects and deformities in the intranasal septum were found to have nasal breathing problems, impaired sense of smell, disturbances of the excretory, inspiratory, air-transporting, and air-heating functions of the nose. Comparative analysis of laryngeal, pharyngeal, tracheal, bronchial, and pulmonary disorders has demonstrated the significant differences in the frequency and duration of these diseases and in the efficacy of their treatment between the patients of the study and control groups. It is concluded that the early recovery of nasal functions, in the first place the respiratory one, is an important precondition for the efficacious prevention of various catarrhal and other laryngeal diseases of the larynx, pharynx, trachea, bronchi, lungs, and ears.

Glabellar flaps in nasal reconstruction

Reconstruction of nasal defects presents a particularly unique challenge for the surgeon. Complex aesthetic subunits and limited available adjacent mobile skin with varying color, texture, and thickness all contribute to this task. The ideal reconstruction of nasal defects recruits tissue of similar color, texture, and thickness to that of the defect. Two versatile local flaps for nasal reconstruction are the glabellar flap and an extension of the glabellar flap, the dorsal nasal flap. The authors describe the use of these two local flaps for reconstruction of nasal defects and modifications of these procedures for certain indications, as well as their use in medial canthal reconstruction.

Complex nasal reconstruction: a case study: composite defect

A woman presents after Mohs excision of a basal cell carcinoma within the right alar. A composite defect of her right upper lip, cheek, and ala is present. Although distressed, her concerns are somewhat alleviated by the prior successful reconstruction of a full-thickness defect of her left ala, some years previously. This content presents the principles of the repair, the surgical plan, and details of the multiple procedures performed for successful reconstruction.

Microvascular reconstruction of nasal defects

Microvascular reconstruction of nasal defects is a complex procedure and must consider 3 nasal components: skin, osteocartilaginous framework, and intranasal lining. These layers can be reconstructed with various flaps and grafts. The commonly used flaps are the first dorsal metacarpal flap, dorsalis pedis flap, auricular helical rim flap, and radial forearm and prelaminated flaps. These flaps can be composed of skin and cartilage or skin and bone. The decision is based on the patient's needs taking into consideration the extent of the defect and presence or absence of nasal septum and columella.

[Funtcional and morphological changes in nasal mucosa in patients presenting with septal deformation]

This study was designed to obtain morpho-functional characteristics of nasal mucosa associated with septal deformation. It has demonstrated disturbances in the mucociluary transport, compromised mucosal immunity, and morphological changes in the nasal cavity.

Nasal septum to columella attachment: a major tip support?

OBJECTIVE

To determine whether surgical section of attachment of the medial crural footplates to the quadrangular cartilage produces loosening of the nasal tip.

STUDY DESIGN

Prospective, observational, before-and-after study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Hispanic patients undergoing septoplasty who required a transfixion incision were included. A six-month postoperative assessment of the nasal tip support was compared with preoperative values. As measures of the nasal tip support, we included tip recoil test, nasolabial angle, tip rotation angle, nasofacial angle, and the Goode method for determining tip projection.

RESULTS

Twenty-seven patients completed the follow-up, and their results are reported. There were no statistically significant differences after septoplasty in any of the five measurements used to assess the nasal tip support (P > 0.05).

CONCLUSION

In this preliminary cohort of Hispanic patients, surgical section of the attachment of the medial crural footplates to the quadrangular cartilage does not produce significant changes in nasal tip support.

Potential predisposition for nasal septal perforation with methotrexate use: report of 2 cases and literature review

Methotrexate is a dihydrofolate reductase inhibitor with application both as a chemotherapeutic agent and as a disease-modifying antirheumatic drug. Although its ability to inhibit cellular proliferation is a desired effect in its role as an antineoplastic agent, this property may also hinder normal physiologic regeneration of the nasal epithelium. This effect may predispose patients to septal cartilage ischemia, necrosis and, eventually, perforation. We report 2 cases of septal perforations in the setting of prolonged methotrexate use and present a literature review. Patient 1 is an 8-year-old boy with juvenile rheumatoid arthritis managed with weekly methotrexate who developed a 4-mm septal perforation with an unremarkable biopsy. This was closed with a mucosal advancement flap without incident. Patient 2 is an 11-year-old boy with non-Hodgkin lymphoma treated with methotrexate. His examination was significant for a large perforation of the dorsocaudal septum. A biopsy was negative for malignancy in this patient. Repair has been deferred-initially for chemotherapy and currently for treatment relapse. We hypothesize that prolonged use of methotrexate alters the balance between physiologic desquamation and epithelial regeneration. This imbalance may promote septal ischemia and predispose patients to the development of septal perforations.

Anchor-shaped nasal framework designed for total nasal reconstruction

BACKGROUND

Nasal frame grafting has been widely used in nasal reconstruction; however, a stable nasal frame with satisfactory functional and aesthetic results is hard to achieve in total nasal reconstruction. In this study, we devised a technique to create an individually designed anchor-shaped nasal frame composed of an L-strut and two C-battens, and applied it in the total nasal reconstruction procedure to achieve satisfactory functional and aesthetic results.

METHOD

In a 9-year period, 17 patients with total nasal defect were treated with autogenous costal grafting utilising forehead flap as the covering. The techniques of the individualised design of the anchor-shaped nasal frame were applied to fit the facial features. All cases were followed for at least 18 months, and outcomes were evaluated separately by the patients and plastic surgeons in terms of aesthetics, stability and function.

RESULTS

Satisfactory results were achieved in most of the cases after the operation. More than 82.4% of the patients in this series were assessed as satisfactory by both groups in the aesthetics survey; more than 76.5% in the stability survey; and more than 64.7% in the function survey. Complications included flap hyperpigmentation (one case), flap-skin paleness (one case), L-strut distortion (three cases) and stuffiness of the nostrils (one case) as well as minor brow elevation of the donor side (five cases).

CONCLUSIONS

The procedure of applying individually designed anchor-shaped nasal frame with forehead flap technique has obvious advantages for restoration of distinct and delicate subunits, stable nasal structure and good nasal function.

Description of columellar defects and its tridimensional remedial techniques

Columella is an important facial component and provides support and projection to the tip of the nose. Columella defects may cause significant aesthetic and functional deformities. We present our case-load of 2007: 61 patients operated in that year had been carried out and concluded. Surgical techniques for the correction of columellar defects were classified as "open tip" and "closed tip". Then, depending on the defect, it was possible to intervene on different structures. Of the 61 patients who underwent corrective surgery, only 6 (<10%) maintained or presented again, after a temporary improvement, with the columellar defect at the end of the follow-up. For all the other patients, the final outcome was more than satisfactory. A very good aesthetic result was obtained with no functional complications. In fact, nose functionality is supported by medial crura, laid one upon the other, providing considerable resistance to the columella.

[Structural and functional reconstruction of nasal mucosa during the postoperative period in patients with deflected nasal septum and chronic hypertrophic rhinitis]

This study was designed to evaluate therapeutic efficiency of Aqua Maris nasal spray during the postoperative period in the patients with deflected nasal dorsum suffering chronic rhinitis. They were divided into two groups comprising 25 subjects each. Patients of the study group received standard treatment supplemented by irrigation of the nasal cavity with Aqua Maris spray (thrice daily). Control patients were given standard therapy alone. Severity of clinical symptoms and nasal ciliary beat frequency (CBF) were assessed before surgery, on days 7 and 14 after it simultaneously with endoscopic examination of the nasal cavity. The degree of impairment of nasal breathing and sensation of dryness in the nose as well as the number of crusts inside the nasal cavity in the patients treated with Aqua Maris decreased significantly compared with the control subjects (p<0.05) while CBF increased (p<0.05).

[Columella defects: yet a challenge!]

The repair of nasal defects is thought to be the most ancient of facial reconstructive procedures, dating back to at least 3000 BC in India. In spite of the development of nasal reconstruction concepts, leading to remarkable esthetic and functional improvements, columella reconstruction is yet a contemporary challenge. Columella defects may result from trauma, infections, carcinoma resection, syphilis, bilateral cleft lip, etc. Maintaining symmetry, contour and function are essential for a successful columella reconstruction. Multiple factors help to determine the optimal repair method, including the size of the defect, its depth and location, and the strength of the underlying nasal framework. This article presents a range of techniques and discusses the application of these methods to specific columella defects. A chronological review of columellar reconstruction procedures used for this partial rhinoplasty is exposed.

Giant rhinophyma in a bronchial asthma patient treated by excision and full thickness skin grafting

A 72-year-old man presented with an unusually severe case of rhinophyma. The pedunculated mass was widely excised and a skin graft from the medial upper arm was applied. A very satisfactory cosmetic result was obtained.

Changes in nasal aesthetics following nasal bone manipulation

Nasal bone fractures are the commonest type of bony facial injury causing aesthetic deformity. The aim of this study was to identify the effect of nasal trauma and fracture manipulation on the aesthetic proportions of the nose, by comparing pre- and post-treatment nasal aesthetics. Thirty-two patients (26 men and 6 women) underwent aesthetic assessment prior to treatment of the injury by closed nasal manipulation, 7 to 10 days after the initial injury. Standard facial aesthetic photographic assessments were performed prior to and following manipulation. Assessment involved measurement of standard nasal aesthetic parameters. In the nasal trauma cohort, the main anomalies in nasal aesthetics were nasal deviation and differences in the nasal aesthetic profile. Nasal fracture manipulation successfully reduced deviation from an average of 35 degrees pre-manipulation to an average of 9 degrees post-manipulation.

One stage reconstruction of nasal defect by reverse flow retroauricular island flap - case series and discussion

A reverse flow retroauricular island flap was successfully used for reconstruction of nasal defects as a one stage procedure in three cases. The length of the pedicle allows its transfer to cover defects of the nose. There was no partial or total flap necrosis and scars were inconspicuous. The patients were very satisfied with the result. Although this technique is of a higher level of difficulty than a conventional washio flap, it allows aesthetically favourable nasal reconstruction by a single stage operation in selected cases.

A surgical algorithm using open rhinoplasty for correction of traumatic twisted nose

In this series, the authors present their experience with correction of the traumatic twisted nose in Asians using open rhinoplasty. A standard surgical algorithm was followed to determine treatment strategies for 92 patients with traumatic twisted nose at the Tri-Service General Hospital in Taiwan between 1 August 2001 and 1 June 2004. A retrospective chart review was performed to collect patient data and surgical details. A follow-up self-evaluation survey regarding satisfaction with nasal function and aesthetics was distributed to all the participants. All the patients underwent open rhinoplasties under general anesthesia. The 87 males and 5 females were 15 to 53 years of age (mean, 28 years). Their postoperative periods were uneventful and without complications. Patient self-evaluations were largely positive, reporting improvement in nasal function. The authors propose a simple surgical algorithm using open rhinoplasty for optimal correction of traumatic twisted nose deformities. The algorithm, which is adaptable to a variety of anatomic deformities, guides surgical decision making that yields consistently satisfactory functional and aesthetic results.

Three siblings with juvenile hyaline fibromatosis

Juvenile hyaline fibromatosis (JHF) is an extremely rare hereditary genetic disease of autosomal recessive transmission that is characterized by large cutaneous tumors commonly involving the scalp, papulonodular skin lesions, flexural joint contractures, gingival hyperplasia, and osteolytic bone lesions. JHF is usually diagnosed in young infants and in children younger than 5 years, and the lesions characteristic of this disorder consist of fibrous tissue and homogenous amorphous eosinophilic hyaline material. We report the case of a 9-year-old girl with severe gingival hyperplasia, nasal enlargement, mild osteoporosis, and multiple papulonodular skin lesions. Her two brothers (7 and 13 years of age, respectively) were also diagnosed as having JHF. In the patient described in this report, the maintenance of oral hygiene after gingivectomy enabled the continued resolution of gingival hyperplasia, although skin lesions recurred and nasal overgrowth persisted.

Reconstructive surgery of the leprosy nose: a new approach

There has still been no reduction in the detection rate worldwide for leprosy, despite supervised multi-drug therapy. In time, leprosy can result in a severe saddle-nose deformity leading to functional problems, disfiguration and stigmatization. In severe cases, only the nasal skin tissue and the lower lateral cartilages are preserved. In such cases, the ideal would be to restore the cartilaginous skeleton but, by contrast with other causes of saddle-nose deformities, this is complicated by the quantity and the poor quality of the remaining nasal mucosa. Leprosy-related saddle-nose deformities are therefore challenging and difficult to reconstruct with the techniques that have been proposed in the past. In this study, 24 patients underwent rhinoplastic surgery involving the use of autogenous costal and/or auricular cartilage or composite grafts. The nasal septum, the upper laterals and the anterior nasal spine were reconstructed with a dorsal onlay attached to a columellar strut with an extension on the proximal side. Before surgery, the saddle-nose deformities were classified according to severity with a new system based on clinical symptoms and signs. Postoperative evaluation was performed at least two years after surgery (N=17). Functional and aesthetic improvement, resorption rate, warping, infection and extrusion were analysed. Functional and aesthetic improvements were achieved in 15/17 patients. None of the patients developed an infection and extrusion or warping of the implants was not observed. The resorption rate depended on the localization and the type of cartilage implant. In general, auricular conchal cartilage implant grafts resulted in less resorption than costal cartilage. Least resorption (4/17 patients) was observed in the dorsal onlay grafts of both conchal (1/6) and costal cartilage grafts (3/11). Resorption of columellar strut implants and shield grafts was observed in 7/17 patients. No resorption was seen of composite grafts (0/4) and alar battens (0/7). Autogenous cartilage implants can be used to reconstruct saddle-nose deformities in leprosy with a minimum risk of complications. The preoperative grade of severity was used as a basis for the development of guidelines for optimal long-term functional and aesthetic outcome.

Correction of the Asian deviated nose with no hump using unilateral bony mobilisation and dorsal septal suture fixation

A deviated nose is corrected by straight realignment and long-term maintenance of the bony and cartilaginous structure. Traditional rhinoplasty usually involves complete separation of both upper lateral cartilages from the septum and bilateral bony mobilisation after osteotomy. In the Asian deviated nose with no hump, these procedures are intrinsically destabilising and may weaken the supporting bony and cartilaginous structure. To avoid these problems, I performed unilateral bony mobilisation with anterior wedge resection and suture fixation of the dorsal septum to the nasal bone without separation of the upper lateral cartilage. This manoeuvre is simple and reproducible and produces satisfactory straightening and maintenance of the nasal dorsum while maximally preserving the structural support. Here, I describe the surgical techniques including the choice of the site of unilateral osteotomy and wedge resection, a new classification of bony deviation, two surgical modifications applied to different types of deviation and rationale of dorsal septal suture fixation. Also, clinical cases of nasal deviation are presented.

Laser remodelling of nodular nasal lupus pernio

Disfiguring nodular nasal lupus pernio is a rare condition that responds poorly to medical management. We have treated three affected patients with carbon dioxide laser remodelling, and report their progress 6 years, 2 years and 16 months following treatment, respectively. Although the abnormal granulomatous tissue was debulked rather than completely excised, the wounds healed within 4 weeks in all patients. The cosmetic results are acceptable and have been maintained in two of the patients, perhaps a reflection of their overall systemic sarcoidosis control.

Scanning electron microscopy of ciliae and saccharine test for ciliary function in septal deviations

OBJECTIVE

To investigate the difference in mucociliary clearance and surface mucosal structure of the nasal septum and lateral nasal wall in patients with and without septal deviation.

METHOD

The saccharine-dye test was used to measure the mucociliary clearance time in both nasal cavities of 20 patients with nasal septal deviation (study group) and was compared with that of 30 patients without septal deviation (control group). Bilateral septal and lateral nasal wall mucosal biopsies were taken from the study group during septoplasty, and unilateral biopsies were taken from 10 of the control group. These biopsies were studied under the scanning electron microscope.

RESULTS

In the study group, mucociliary clearance on the side opposite the septal deviation was significantly slower than on the other side. Mucociliary clearance on both sides of the deviated septum of the study group was significantly slower than clearance in the control group. There was no statistically significant difference in the distribution of mucosal cilia of the cavities on either side of the deviated septum in the study group, nor between the distribution in the study group and controls.

CONCLUSION

Patients with septal deviation display no change in mucosal surface anatomy but have decreased mucociliary activity on both sides of the deviation, the least activity being on the side opposite the deviation.

Saddle nose deformity in a patient with Crohn’s disease

Crohn’s disease is a chronic idiopathic inflammatory disease of the bowel, and in most cases it involves the small bowel and colon. Extraintestinal manifestations occur frequently and multiple organ systems may be affected. In contrast, nasal manifestations are extremely rare and only a few cases have been reported to date. Saddle nose deformity in a patient with Crohn’s disease has not been reported in the English literature. We report a case of such a deformity and the current literature on nasal manifestations in Crohn’s is reviewed. The normal diagnostic and therapeutic features are also discussed.

[Clinico-anatomic characteristics of the tip of the nose]

The anatomy of the tip of the nose is reviewed with description of clinical manifestations in different variants of anatomical structures of the tip of the nose. Thick skin problem and specific features of surgical treatment of nasal tip deformities in thick, porous skin are considered.

Tophaceous gout presenting as a dorsal nasal lump

A literature review reveals that gout has been described as affecting many sites in the head and neck region, both in the arthritic and tophaceous form. Gout can often mimic malignancy or infection, and has been described as causing acute airway problems requiring emergency tracheotomy. Here we describe the first published case of tophaceous gout affecting the soft tissues overlying the nasal bones. The patient presented with a bony, hard, dorsal hump and requested aesthetic rhinoplasty. We also describe an endoscopic technique for removal of tophi using a powered microdebrider system with a protected burr head. Endoscopic powered microdebrider blade excision of tophi affecting the limbs has already been described, with reduced complications when compared with conventional curettage and debridement techniques. This is the first such application to the nose.

[Entomophthoramycosis (zygomycosis) caused by Conidiobolus coronatus in Mato Grosso (Brazil): case report]

Zygomycosis is a subcutaneous mycosis caused by soil fungi, such as Conidiobolus coronatus. In general, the main clinical manifestation is a chronic rhinofacial tumor. We report the first case of zygomycosis (entomophthoramycosis) caused by Conidiobolus coronatus, occurring in Mato Grosso, West Brazil.

An absolute vascular milieu for primary bone graft in aesthetic nasal reconstruction

Restoration of a composite nasal defect with an aesthetically acceptable vascularized full-thickness soft tissue cover and a primary bone graft in a surgically unscarred area at the same stage requires that the flap have a complete formal inset from all the sides, for enhancement of the milieu interior. This article addresses such a situation, which required the use of a cantilever bone graft simultaneously with an interpolated midline forehead flap based on the supratrochlear vessel and transferred on a deepithelialized bridge segment, which allowed an absolute inset from all the sides. The eventual aesthetic outcome was satisfactory after a secondary surgery for nasal tip correction using conchal cartilage graft for tip framework. The procedure has allowed placement of the bone graft in an unscarred bed, with a complete inset of the vascularized full-thickness soft tissue cover. This provided the graft with the ideal vascular milieu for survival and consolidation and achieved an aesthetically acceptable soft tissue reconstruction of the nose with minimal donor-site morbidity. It obviated the need for the staged procedures and provided a secure vascular milieu for the primary bone graft.

Frontoethmoidal encephalomeningocele: new morphological findings and a new classification

Given a lack of a comprehensive classification for the frontoethmoidal encephalomeningocele (FEEM), clinical, photographic, and computed tomography (CT) data of 23 nonoperated patients were reviewed. Extracranial pathological findings of interest included herniation masses, facial deformities, and frontonasal bone morphology. Intracranial pathological findings of interest included morphology of the anterior cranial floor and brain malformations. Stereographic software processed data from a new-generation CT scanner into three-dimensional pictures that revealed some interesting morphological findings not often appreciated (eg, herniation mass without underlying external bone defect; mass at location far from external bone defect ["sequestrated cephalocele"]; new type of external bone defect characterized by a combination of nasoethmoidal and naso-orbital defects; correlation between mass, external bone defect, and exit pathway of herniation). Given these observations plus current knowledge available in the medical literature, a new classification system was developed that covers phenotypes and severity of the disease. The "FEEM classification" is an alphanumeric system based on facial deformities, external bone defect, exit pathway of herniation, and malformation of brain. It was tested in 42 patients for usability and validity. When combined with a newly designed "FEEM diagram," relevant pathological findings can be recorded in an objective manner so that diagnosis becomes more precise and uniform and comparison of outcome is possible. It also emphasizes the fact that FEEM has a range of manifestations governed by dynamic interaction between structural defects and herniation. Each clinical entity is a final result of its own disease course (stable, progressive, or regressive FEEM), with a varying degree of communication between the external mass and the central nervous system.

[Clinical and morphological parallels in combined deformations of the nose]

Analysis of clinical characteristics of 56 patients with combined deformations of the nose and morphological (histological and histochemical) changes in the nasal septal cartilage in 20 patients showed that common nasal deformations are complicated with age, impeding nasal respiration. The intensity of dystrophic changes in chondrocytes and intercellular cartilaginous matrix depends on the duration of posttraumatic or congenital deformation but not on its clinical severity. This necessitates earlier interventions, before the development of pronounced deformation of the whole nose and deterioration of nasal respiration.

Facial growth after middle turbinate resection: an experimental study in the rabbit

BACKGROUND

The aim of this study was to determine the effects of total middle turbinate resection on midfacial growth through a morphometric analysis on an animal model.

METHODS

Twenty-eight male New Zealand white rabbits were used. The animals were divided into three groups: group 1, elevation and relocation of the nasal bone was performed; group 2, concha resection was performed; group 3, control group with no surgical procedure. The surgery was done at 8-10 weeks of age and the skull of each subject was sampled as they reached maturity. The determined distances then were measured by using landmarks identified on skull. The supplied data were evaluated by using the Mann-Whitney U test.

RESULTS

Deviation of the nasal axis to the opposite side of the resected concha and an increase in the width of nasal bone were observed only in group 2. In group 1, an increase of nasal bone length and zygomaticonasal distances was determined in both the operated and the unoperated sides of nasal bones.

CONCLUSION

This animal experiment showed that operations on the nasal bone or concha resection affected the midfacial growth in rabbits. The effects of middle turbinate resection to midfacial development should be evaluated by additional studies. We recommend only limited, conservative surgical procedures on the middle turbinate, saving all the vital mucosa, periosteum, and bone.

A functional and aesthetic solution for saddle nose deformity: the use of the inferior turbinate bone

The use of a new autologous material, the inferior turbinate bone, for nasal augmentation is presented together with surgical treatment of a 24-year-old male patient with moderately severe saddle nose deformity. In the postoperative period, no complications were observed. Photographs and three-dimensional computed tomography views obtained 13 months after the operation showed that the reconstruction area was highly free of postoperative resorption. The patient's complaints disappeared, and he was satisfied with functional and cosmetic results. Moreover, a histologic evaluation which was made to assess the depth of the glandular component showed that the inferior turbinate bone could be used over the nasal dorsum in a smoother shape, retaining its overlying soft tissue.

The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty

We suggest that it is possible to correct the stigmata of the post-traumatic nasal deformity by means of an upper buccal sulcus approach alone. This approach is demonstrated in a series of ten cadaveric subjects for the correction of nasal skeletal deviation or bossing. Furthermore, the technique, which avoids internal nasal scarring and violation of the internal nasal valve, has been successfully employed in four patients with a minimum of 9 months follow-up. We suggest that it is possible to conserve the internal nasal valve and avoid problems of nasal tip retractions using this approach in selected cases.

Surgery of the lateral nasal wall and ethmoid: effects on sinonasal growth: an experimental study in rabbits

OBJECTIVE

To assess the impact of lateral nasal wall surgery on sinonasal growth

METHODS

Twenty young New Zealand White rabbits, 6 weeks of age, were included in this experimental study. Surgery was performed on two groups of ten animals each (series I and II). Entrance to the left nasal cavity is achieved through the nasal dorsum via mobilization and rotation of the left nasal bone. Series I: partial resection of the lateral nasal wall (including the ostium to the maxillary sinus) on the left side. Series II: partial resection of the lateral nasal wall and anterior ethmoid. Follow-up period was 20 weeks. Twenty rabbits served as controls.

RESULTS

In series I, all skulls have grown normally. In series II the nasal dorsum has also developed symmetrically. Snout length and growth of upper jaw are normal; there is no malocclusion. Three skulls show a slight deviation of the nasal dorsum (two to the left, one to the right). Morphometric measurements of 20 points on the skulls show no significant difference between the control group and the experimental series I and II.

CONCLUSION

This experimental study demonstrates that visually controlled partial resection of the bony sinonasal wall, with or without resection of the anterior ethmoid does not affect later development of nose and upper jaw on condition that eventually underlying cartilage is preserved. Contradictory results from other experimental studies, previously published and concerning negative effects of sinus surgery, might be attributed to surgical traumatization of intranasal cartilage structures, in particular, the upper lateral cartilages.