Schwannoma of the lateral nasal wall: A Case Report

Nasal schwannomas account for about 4% of head and neck schwannomas. We report a rare case of lateral nasal wall schwannoma presenting as a nasal mass in a 70-year-old man.

Septodermoplasty: Make It Easier

Septodermoplasty (SDP) is a technique that presents a surgical option for the treatment of recalcitrant epistaxis from hereditary hemorrhagic telangiectasia. It involves the removal of affected nasal epithelium, replacing it with a split thickness skin graft (STSG). However, the inherent challenges with SDP are that owing to the floppy and unstable nature of the STSG, especially if simultaneously grafting the lateral nasal wall in addition to the septum and nasal floor, there is a risk of inadvertently stripping and displacing the STSG from its intended position. In this article we offer some techniques that utilize microdebrider for addressing mucosal lesions and fixate silastic sheet on floppy STSG as a scaffold to make it firm and easy to handle in order to hold the graft right in place.

An Endoscopic Endonasal Nasopharyngectomy with Posterolateral Extension

Background Invasion depth influences the choice for extirpation of nasopharyngeal malignancies. This study aims to validate the feasibility of endoscopic endonasal resection of lesions with a posterolateral invasion. As a secondary goal, the study intends to propose a classification system of endoscopic endonasal nasopharyngectomy determined by the depth of posterolateral invasion. Methods Eight cadaveric specimens (16 sides) underwent progressive nasopharyngectomy using an endoscopic endonasal approach. Resection of the torus tubarius, Eustachian tube (ET), medial pterygoid plate and muscle, lateral nasal wall, and lateral pterygoid plate and muscle were sequentially performed to expose the fossa of Rosenmüller, petroclival region, parapharyngeal space (PPS), and jugular foramen, respectively. Results Technical feasibility of endonasal nasopharyngectomy toward a posterolateral direction was validated in all 16 sides. Nasopharyngectomy was classified into four types as follows: (1) type 1: resection restricted to the posterior or superior nasopharynx; (2) type 2: resection includes the torus tubarius which is suitable for lesions extended into the petroclival region; (3) type 3: resection includes the distal cartilaginous ET, medial pterygoid plate, and muscle, often required for lesions extending laterally into the PPS; And (4) type 4: resection includes the lateral nasal wall, pterygoid plates and muscles, and all the cartilaginous ET. This extensive resection is required for lesions involving the carotid artery or extending to the jugular foramen region. Conclusion Selected lesions with posterolateral invasion into the PPS or jugular foramen is amenable to a resection via expanded endonasal approach. Classification of nasopharyngectomy based on tumor depth of posterolateral invasion helps to plan a surgical approach.

The Relationship between Lateral Nasal Wall Collapse and Nasal Obstruction, a case-control study

Objectives In clinical practice, lateral nasal wall collapse during forced inspiration is widely regarded as a sign of nasal obstruction or criterion indicating nasal valve surgery. This study aims to evaluate the relationship between the degree of lateral nasal wall collapse and subjective nasal obstruction. Design Case-Control study Setting Tertiary centre hospital Participants Case group consisted of 24 patients who had been diagnosed with a deviated nasal septum or nasal valve stenosis. Control group consisted of 27 volunteers with no nasal obstruction symptoms and no septal deviation on nasal endoscopy. Main outcome measures Lateral nasal wall collapse is determined by the degree of lateral nasal wall triangle (LNWT) area reduction on frontal view during forced inspiration compared to quiet inspiration. LNWT area ratio of the patient and control groups was compared. The relationship between the lateral nasal wall collapse and clinical factors including symptom scores, nasal valve angles, skin thickness were evaluated. Results The average LNWT area ratio of the patient (n=24) and control groups (n=27) was 0.96 and 0.83 respectively (p=0.001). Symptom score (NOSE and VAS) is not related to the degree of lateral nasal wall collapse. Moreover, nasal valve angle and skin thickness were also not related to the degree of lateral nasal wall collapse. In 14 of the 19 patients, the more obstructed side corresponded to the side of narrower nasal valve angle, and 5 were not. Conclusion Lateral nasal wall collapse is not related to a patients’ nasal obstruction.

350 Cross Over Septal Flap Technique for Choanal Atresia Surgery: Two Centre Series with Outcomes

Introduction Choanal atresia (CA) is a congenital obstruction of the posterior nasal aperture due to nasal cavity canalisation failure. Endoscopic endonasal surgery has led to successful CA repair and fewer complications compared to open surgery. We describe our surgical technique that uses septal mucosal flaps without need for stenting or subsequent intubation. Method A multicentre retrospective review of patients who underwent surgery using the cross over septal technique. Patient demographics and outcomes were recorded. Flap design: bilateral vertical septal mucosa incisions are performed on either side of the posterior third of the septum to form two mucoperiosteal flaps. The posterior vomer and atretic plates are removed. One flap is pedicled superiorly and rotated over the bare sphenoid rostral bone. The contralateral flap is pedicled inferiorly and rotated to cover exposed bone of nasal cavity floor. Lateral nasal wall mucosal integrity is maintained. This technique is used both for unilateral and bilateral atresia. Results Twelve patients from 2013 to 2020 were included. Age range was 0.07-50 years, male to female ratio of 1:5. Ten patients had unilateral CA, two had bilateral. Nine had bony CA, the remainder mixed. 5 patients (mean age 2.8 years) underwent second-look endoscopy under sedation an average 36 days following primary surgery. Conclusions The cross over technique for CA has low morbidity and 100% success in our multicentre series. Use of mucoperiosteal flaps to cover the exposed bone, removal of vomer and minimal instrumentation to the lateral nasal wall are the best ways to avoid postoperative stenosis.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall

Background: The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip. Methodology: Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the “shoulder” of the inferior turbinate and the pyriform aperture. Results: The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the “shoulder” of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides. Conclusions: We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

Mucocele of a giant inferior turbinate concha bullosa mimics a nasal mass: case report

Background The concha bullosa is a pneumatized nasal turbinate commonly middle turbinate but that of the inferior turbinate is an uncommon entity. A giant inferior conchal pneumatization with mucocele formation is not reported in the literature till now. Case presentation A 17-year-old female patient presented with bilateral severe nasal obstruction. Anterior rhinoscopy and endoscopic examination revealed a giant mass which filled the left nasal cavity completely, pushing the septum to the contralateral side. The paranasal sinus CT showed a mass in the left nasal cavity ballooning the whole nasal cavity with compression of the nasal septum to the right side. MRI was done and the lesion was hyperintense in T2 MRI sequences and hypointense in T1 sequences consistent with a cystic lesion. The patient was consented and prepared for endoscopic resection under general anesthesia. The lesion was completely separated from the nasal septum and the orbit but attached to the lateral nasal wall at the site of origin of the inferior turbinate. Conchoplasty was done and patient follow-up for 9 years is excellent with complete disappearance of all patient symptoms. Conclusions Concha bullosa of the inferior turbinate should be considered in the differential diagnosis of nasal tumors, nasal cystic lesions, and preoperative evaluation of endoscopic sinus surgery. Also, a systematic approach for dealing with nasal lesions with thorough examination and radiological review will be of great value in decision-making. The anatomy of the paranasal should be thoroughly examined prior to endoscopic sinus surgery to develop treatment strategies and to prevent possible complications.