Trans-nasal endoscopic holmium: YAG laser correction of choanal atresia

Five patients with choanal atresia were treated, using a trans-nasal endoscopic Holmium:YAG laser. The age of patients ranged from 15 months to 53 years. The nasal endoscope provides excellent visualization. The advantage of the Holmium:YAG laser is its fibre-optic delivery, allowing the laser to be hand-held, giving greater precision. Good nasal airways were achieved in four out of five cases with a single treatment. The procedure was found to be safe, quick, with minimal morbidity and a shorter in-patient stay.     

Choanal atresia--a patient care study

This study is about a ten year old girl called Nicola who was admitted to the Royal Liverpool Childrens Hospital (RLCH) to have corrective surgery for Unilateral choanal atresia. Choanal atresia occurs as a result of failure of canalisation of the bucconasal membrane. Bilateral atresia causes total nasal obstruction and unless immediate treatment is initiated asphyxia will occur, because a new-born infant will not breathe through the mouth. The diagnosis is confirmed when a catheter fails to pass from the mouth to the nasopharynx. Unilateral atresia may cause respiratory difficulty in the neonatal period in which case surgery is usually advised. If the nasal obstruction is not gross, surgical correction can be delayed.     

Ethmoid adenocarcinoma perforating the cribriform plate in the horse

This clinical report describes an 8-year-old Thoroughbred mare that was presented for evaluation of a chronic, unilateral nasal discharge. Findings on physical examination, radiology, and video-endoscopy supported a clinical diagnosis of ethmoidal hematoma. After surgical ablation of the mass a defect was detected in the cribriform plate. At necropsy a 1.5 cm aperture was identified in the left cribriform plate allowing direct communication between the fundus of the nasal cavity and the cranium. Histology of the mass identified tissue consistent with an adenocarcinoma. History of profuse epistaxis warrants further investigation to differentiate malignant lesions from the more common benign lesions. During surgical ablation of large, space-occupying masses of the caudodorsal nasal cavity the cribriform plate should be examined for defects or secondary erosive lesions.     

Nasal polyps in children

The inflammatory nasal polyp is the most common benign or malignant nasal mass seen in children. Nasal polyps in the pediatric population appear to occur as inflammatory responses to bacterial infections. In 33% of the patients with polyps whom we studied, antral choanal polyps were noted, and in 20% of the patients the polyps were unilateral but not antral choanal. In 18% of the patients the polyps were bilateral and in an additional 29% they occurred bilaterally in association with cystic fibrosis. History of an allergy is infrequently associated with nasal polyps; allergies are potentially major contributing factors to nasal polyps only in patients without cystic fibrosis whose nasal polyps are bilateral. Patients with antral choanal polyps are most successfully managed by simultaneous Caldwell-Luc antrostomy and polypectomy. Sixty percent of patients with nasal polyps and cystic fibrosis are adequately managed with a single intranasal polypectomy. Simultaneous sinus surgery and polypectomy should be considered for all patients with recurrent polyps and for all patients with clinical or radiographic evidence of significant sinusitis. Complications, including epistaxis and intranasal synechia, occurred in 3% of the 170 surgical procedures performed.     

Axial osteomalacia: report of a new case with selective increase in axial bone mineral density

We report a case of a rare congenital nasal malformation. A young male patient was seen with a unilateral duplication of the left nostril. According to the morphogenetic classification, described by van der Meulen, this nasal malformation could be classified as a type IV nasal dysplasia. The other observed abnormalities that were seen were part of the CHARGE association, which is defined as coloboma of the iris, heart deformities, choanal atresia, retarded growth, genital and ear deformities. The patient underwent a surgical correction of the nose using an L-approach, yielding a satisfactory result 1 year postoperatively. Details of the case and a review of the scarce literature are presented.     

Which occupational carcinogens to regulate and by whom?

We report on a child with choanal atresia and deletion 9p. A review of the literature documented one previous instance of choanal atresia in a patient with del(9p). Choanal atresia may be part of the spectrum of malformations in the deletion (9p) syndrome and its presence should prompt a search for this particular deletion as part of the differential diagnosis.     

Protective effects of vitamins C and E in hypoxia

The choanal atresia is a rare congenital malformation. Its clinical diagnosis is easy and must be done at the birth by the midwife or the obstetrician. We recommend the aspiration in all hospital maternity wards. This attitude avoids the unrecognized of an unilateral choanal atresia. The authors report three cases with a successfully treatment.     

Cardiovascular malformations associated with choanal atresia

In this study, cardiovascular malformations were present in 11 of 63 (17.5%) patients with choanal atresia. The most frequently encountered cardiac lesions were ventricular septal defect and patent ductus arteriosus, while cyanotic heart disease was uncommon.     

Penetrating head injury caused by weed--case report

A case of penetrating head injury caused by weed was reported. A 69-year-old man fell from a bicycle and was stuck by the hard stalk of weed through the right nasal cavity. On admission the patient was fully alert and with no neurological deficits. The weed was pulled out at an out-patient department and then he became semicomatose and hemiplegic on the left side together with an occurrence of nasal bleeding. Subsequent computed tomographic (CT) scan showed an intracerebral hematoma in the right frontal lobe. The hematoma was immediately evacuated and the dural defect, lateral to the cribriform plate, was closed. It is stressed that neuroradiological evaluation with CT scan and/or magnetic resonance imaging (MRI) is mandatory because an information about an anatomical location of penetrating objects and intracranial complications are essential to a decision-making of surgical strategy. The objects should be urgently removed in a surgical exposure of the intracranial lesion and the contused brain should be debrided with a repair of the lacerated dura mater.     

An explanation for the increasing incidence of testis cancer: decreasing age at first full-term pregnancy

We report confirmation of the site of leakage in two patients with spontaneous cerebrospinal fluid (CSF) rhinorrhoea by demonstrating CSF leaking on MRI. Both patients had midline anterior cranial fossa floor (cribriform plate/fovea ethmoidalis) dural-bone defects with arachnoid herniation with or without brain herniation into the upper part of the nasal cavity on MRI, which was subsequently confirmed surgically. Corresponding to the history of postural induction or aggravation of the rhinorrhoea, the CSF leak was demonstrated by the appearance of or increase in the sinonasal fluid collection by imaging the patient in the position of maximum leakage following initial images in the supine position.     

Malformation of the tear ducts associated with clefts in the face (author's transl)

A case of malformation of the tear duct associated with clefts in the face is described. To our knowledge this combination has not been described before. The whole symptoms complex consisted of: bilateral cleft lip upper jaw and gum, choanalatresia, mucocele of the left nasal cavity from adhesions of the lower concha with the nasal septum, cystic dilatation of the tear sac at the connection to a bony naso-lacrimal duct. Right inguinal hernia, syndactyly of the first and second left toes, iris-chroid coloboma right with congenital cataract and unilateral right convergent squint. Because of the advanced dacryocystitis on the basis of the congenital dacryostenosis, and external dacryostorhinostomy (modified after Kaleff 1937) was performed after pre-treatment by instillation of antibiotic solutions in the tear ducts. At the same time the nasal cavity mucocele was opened by partial excision of the lower concha and opening the choanal atresia. After a post-operative course free of complications and with clear patency of the tear ducts the oral surgical operation was done--closure of the face clefts. The chromosome analysis was normal the only abnormal result here was an unexplained slow rate of multiplication of lymphocytes in four cultures inoculated at various points of time. Because we could not find any hereditary factors, this symptom complex is probably due to exogenous embryo damage during the early development phase.     

CHARGE syndrome: report of 47 cases and review

The acronym CHARGE refers to a syndrome of unknown cause. Here we report on 47 CHARGE patients evaluated for the frequency of major anomalies, namely coloboma (79%), heart malformation (85%), choanal atresia (57%), growth and/or mental retardation (100%), genital anomalies (34%), ear anomalies (91%), and/or deafness (62%). In addition, we comment on anomalies observed very frequently in neonates and infants with the CHARGE syndrome, including, minor facial anomalies, neonatal brain stem dysfunction with cranial nerve palsy, and, mostly, internal ear anomalies such as semicircular canal hypoplasia that were found in each patient that could be tested. We propose several criteria for poor survival including male gender, central nervous system and/or oesophageal malformations, and bilateral choanal atresia. No predictive factor regarding developmental prognosis could be identified in our series. A significantly higher mean paternal age at conception together with concordance in monozygotic twins and the existence of rare familial cases support the role of genetic factors such as de novo mutation of a dominant gene or subtle sub-microscopic chromosome rearrangement. Finally, the combination of malformations in CHARGE syndrome strongly supports the view that this multiple congenital anomalies/mental retardation syndrome is a polytopic developmental field defect involving the neural tube and the neural crests cells.     

A comparison of the nasal mask and the nasopharyngeal airway in paediatric chair dental anaesthesia

This study compared the quality of anaesthesia and surgical access afforded by two techniques for the administration of anaesthesia during paediatric chair dental procedures. A total of 50 ASA 1 paediatric day case patients were randomly assigned to receive anaesthesia through either the traditional Goldman nasal mask or through a nasopharyngeal airway. Patients in the nasal mask group were judged to have significantly worse airway patency (p = 0.0001) and significantly more episodes of airway obstruction (14 vs. 4; p = 0.0032) than those in the nasopharyngeal airway group. Anaesthetic, surgical and oxygen saturation data did not differ significantly between the two groups. Operating conditions were universally graded as excellent in the nasopharyngeal airway group, while those in the nasal mask group were graded as excellent/good in only 79% of cases (p < 0.0001). These results suggest that better quality anaesthesia and operating conditions can be achieved by using a nasopharyngeal airway rather than the traditional nasal mask for the administration of anaesthesia to paediatric chair dental patients.     

Prescribing medications and malpractice suits: clear, consistent documentation is the key

BACKGROUND: Adenoid hyperplasia is one of the most common reasons for nasal obstruction in childhood. The consequences of a nasopharyngeal obstruction on the airflow in the nasal cavity and the epipharynx were investigated. MATERIALS AND METHODS: In a model of a nose we conducted experiments with adenoids of different size, documenting their influence on inspiratory and expiratory nasal flow. Rhinoresistometry was performed to obtain further information concerning resistance and turbulence. RESULTS: The flow experiments showed no alterations of the inspiratory nasal flow regardless of adenoid size. Instead the adenoid had a significant influence on the direction of the expiratory nasal flow in the cavity. Depending on the extension of the hyperplasia, parts of the nasal cavity were excluded from the flow. Rhinoresistometry showed that relation between nasopharyngeal obstruction and nasal resistance was nonlinear. CONCLUSION: Adenoid hyperplasia affects only expiratory nasal flow. In our model a critical mass seemed to be reached in case of more than 60% nasopharyngeal obstruction. A narrowing of the epipharynx up to 50% of its volume has no significant effects on nasal resistance.     

Retinoid X receptor expression in the normal pituitary and clinically ''non-functioning'' pituitary tumours

Nasal chondromesenchymal hamartoma is the suggested appellation for a tumefactive process of the nasal passages and contiguous paranasal sinuses in seven children with a detectable mass in the nose. With the exception of one patient who was 7 years of age at diagnosis, the others were 3 months of age or less upon recognition of the mass. Two children were diagnosed in the first 2 weeks of life. Imaging studies showed a complex solid and cystic mass or masses filling the nasal cavity and extending into the ethmoid sinuses in most cases. Erosion of the surrounding bone, including the cribriform plate, resulted in an intracranial component in the four cases. Surgical resection was the treatment of choice despite its technical difficulties that often necessitated a combined intranasal and intracranial approach. Residual disease with continued growth in one case was the clinical outcome in two children, and the remaining five patients have not experienced any further difficulties. The piecemeal fragments of tissue disclosed a collage of histologic features, but the basic morphologic elements were well-demarcated nodules of cartilage with some variation in the cellular density and maturation of the chondrocytes, a myxoid to spindle cell stroma, focal osteoclastlike giant cells in the stroma, and erythrocyte-filled spaces resembling those of the aneurysmal bone cyst. Two of the tumors were less polymorphous or complex in their spectrum of histologic features. These nasal masses have similarities to the so-called chest wall hamartoma or mesenchymal hamartoma of the chest wall in terms of the clinical presentation in infancy and the basic cartilaginous character of both entities. There is a degree of presumption in the designation of these nasal and chest wall tumors as hamartomas because the pathogenesis has not been established for either entity.     

Extensive form of aplasia cutis congenita: a new syndrome?

Aplasia cutis congenita is a heterogeneous group of conditions usually involving the scalp as well as any other part of the body and is associated with a number of other congenital anomalies. We report on a newborn male with almost complete absence of skin and subcutaneous tissue in association with choanal atresia, syndactyly, imperforate anus, pulmonary hypoplasia, and other anomalies. To our knowledge, this condition, not only in the extent of the lesion but the associated anomalies, has not been reported previously.     

Collapse of the nasal endotracheal tube in the nasal cavity

A 27-year-old female with maxillary maldevelopment was admitted for mandibular sagittal splitting osteotomy with mandibular progeny. General anesthesia was induced with 100 mg of propofol and 8 mg of vecuronium. When a soft and preformed 7.0 mm North-Polar-nasotracheal tube (Portex) was inserted into the nasopharynx through the left nasal cavity, it was very difficult to advance beyond the choana. After nasotracheal intubation, the buking became harder than before when she had been ventilated with a face mask. The peak airway pressure had reached higher than 50 cmH2O with ventilation of 500 ml tidal volume. Bronchoscopy revealed that the fiberscope (3.5 mm O.D.) could not go through the choanal stenosis, because it was too narrow. Therefore, she had to be intubated by a spiral tube, 6.0 mm I.D., through the other nasal cavity with assistance of bronchoscopy, instead of the North-Polar-tube. So, we have to pay attention to the possibility of compression and collapse of a soft nasotracheal tube in the nose of the patient with choanal stenosis due to maxillary maldevelopment.     

Primary non-Hodgkin lymphoma of the sinonasal cavities: correlation of CT evaluation with clinical outcome

PURPOSE: To determine retrospectively the primary site of origin of sinonasal lymphomas with computed tomography (CT) and correlate the CT findings with histologic phenotype and clinical outcome. MATERIALS AND METHODS: In 24 patients with stage I and II non-Hodgkin lymphomas of the sinonasal cavities, the CT appearances and clinical data were reviewed retrospectively. RESULTS: The sites of primary tumor determined at CT were the nasal cavity in 13 patients, the ethmoidal sinus in three patients, and the maxillary sinus in eight patients. B-cell lymphomas were found mainly in the maxillary sinus, while T-cell lymphomas were found in the nasal cavity and ethmoidal sinus (P < .005). The 5-year survival rates in relation to the primary site of the tumor were 64% for the nasal cavity, 50% for the ethmoidal sinus, and 100% for the maxillary sinus (P = .26). CONCLUSION: Patients with B-cell primary lymphoma of the maxillary sinus tended to have a good prognosis in contrast to those with T-cell lymphomas that originated from midline structures. The primary site determined at CT appears to be correlated with the histologic phenotype and clinical outcome.     

Safety assurance for occupational tumors in agriculture]

Congenital aural atresia is viewed by many physicians as a poorly characterized, arcane, clinical entity associated with a variety of hearing deficits. In fact, congenital aural atresia represents a disease spectrum predicated on the reliable embryological development of the first and second branchial apparatus. All degrees of microtia, canal atresia, and middle ear structure malformation are identified by this disease process. Many classification schemata have been proffered since the turn of the century to assist the otologist with a better means of assessing the patient's suitability as a surgical candidate. Clinical, audiological, and radiographic evaluation of congenital aural atresia is essential in selecting the appropriate candidates for surgery or hearing amplification. The high resolution CT scan has advanced the understanding and preoperative assessment of this condition. Surgical repair of the external ear and middle ear malformations is effective in properly selected patients. Essential background information, relevant embryology, patient evaluation, treatment, and current controversies related to congenital aural atresia are discussed.