External Nasal Deformity Research Articles

Comparison of the post-operative outcomes between different surgical techniques for inferior turbinate reduction surgery: A cross sectional study.

To compare and measure post-operative outcomes among various surgical techniques for reducing inferior turbinate hypertrophy (ITH), and to identify the factors associated with the clinical outcomes of turbinoplasty in patients with this condition. A cross-sectional study was carried out from January 2021 to December 2022 at the Otorhinolaryngology Department of King Abdulaziz Medical City in Riyadh, Saudi Arabia. A total of 301 adult patients with ITH were included and were divided into different groups. Postoperative follow-up assessments were completed after one week, one month, and 6 months to evaluate outcomes and complications associated with each surgical technique; descriptive analysis, cross-tabulation, and exact logistic regression were utilized as data analysis methods. Most patients in both groups experienced partial or complete improvement after surgery, with 92% showing positive outcomes. Common clinical signs included deviated nasal septum deviation and external nasal deformity, while nasal obstruction was most frequently reported as the primary symptom. Post-surgery bleeding occurred in 3.7% of cases; no adhesions were noted. Microdebrider, medial flap, out-fracture, and submucosal diathermy techniques all demonstrated significantly higher improvement rates than others. The identified techniques with higher improvement rates offer evidence-based guidance for selecting optimal surgical approaches, while the study's limitations warrant further prospective research to validate these findings. Ultimately, it contributes valuable knowledge to the field of otorhinolaryngology, aiming to enhance patient outcomes and improve the management of ITH worldwide.

Analysis of the Effectiveness of Anterior Septal Reconstruction in Asians.

Background: Although anterior septal reconstruction (ASR) is effective, it is less commonly employed in Asian patients compared with the septal extension graft technique, even in cases of severe antero-caudal septal deviation. Objective: To compare airflow and patient perceptions after ASR in patients of Korean descent with caudal septal deviations and external nasal deformities, we considered the potential tendency of their septal cartilage to be smaller and less robust compared with that of Caucasians. The measurements were conducted using acoustic rhinometry and patient-reported outcomes. Methods: We analyzed 103 patients using preoperative and 3-month postoperative assessments: Korean version of the Standardized Cosmesis and Health Nasal Outcomes Survey (K-SCHNOS), obstructive (SCHNOS-O), and cosmetic (SCHNOS-C) scores, and minimal cross-sectional area (MCA) measured by acoustic rhinometry. Results: Among 103 patients (mean age 33.36 years, median age 32 years, age range 17-70 years, 77 men [75%], and 26 women [25%]), the average follow-up period for the patients was 264.6 days (median 202 days and range 13-1540 days), SCHNOS-O scores improved significantly from 64.02 ± 4.89 to 19.31 ± 4.45 after ASR (p < 0.001), as did SCHNOS-C scores, improving from 60.61 ± 7.71 to 14.25 ± 4.66 (p < 0.001). MCA increased from 0.30 ± 0.16 cm2 to 0.56 ± 0.38 cm2 (p < 0.001). Conclusions: As measured by MCA and SCHNOS scores at 3 months postoperatively, ASR proves valuable for correcting antero-caudal septal deviations and nasal deformities in Asians, despite the tendency of their septal cartilage to be smaller and less strong compared with that of Caucasians.

Clinical manifestations of nasoethmoid-central midface and lateral mid midface trauma: an analytical study

Background: Patients with facial trauma were analyzed to determine the clinical presentation of fractures of the naso-ethmoid, mid and lateral face. Methods: 61 patients in the trauma unit of Dayanand Medical College were prospectively analyzed during a period of two years (August 2013 to August 2015). Results: Road traffic accidents were the major cause of fractures (72.13%) followed by assaults (14.75%) and falls (8.19%). The age group commonly affected was 21-30 years (54.09%) followed by 31-40 years (13.11%). Facial fractures were more in males, the females being 5 times less at risk. Epistaxis, swelling, tenderness, nasal obstruction, external nasal deformity and crepitus were noted in almost all patients. Ecchymosis, telecanthus and CSF rhinorrhea were noted in 90.9%, 72.7%, and 18.18% respectively. 90% presented with circumorbital ecchymosis, facial edema and anterior open bite. Other symptoms were epistaxis (81%), infraorbital nerve anesthesia and surgical emphysema (47.6%) and lengthening of face (42.8%). The commonest presentation was circumorbital ecchymosis (95.5%), subconjuctival hemorrhage (85.7%), flattening of cheek and step deformity at the infraorbital margin (81%). Facial edema was seen in 76% and trismus in 42.9%. Conclusions: Common symptoms and signs of nasoethmoid fractures included epistaxis, swelling and tenderness, nasal obstruction, external nasal deformity and crepitus in all patients, circumorbital ecchymosis in 90% and telecanthus in 73%.

Evaluation of the Patient with Nasal Obstruction.

Patients often present with a complaint of nasal blockage, either primarily, or in conjunction with aesthetic concerns. The evaluation of the patient with nasal obstruction involves a comprehensive history and a detailed physical examination. The nose is an organ in which form and function are inseparable, and as such, examination of the patient with nasal obstruction must focus not only the internal structures that may cause obstruction of the nasal airway, but also the external structure of the nose as it impacts nasal breathing. Detailed facial analysis and a systematic nasal examination will reveal details regarding nasal obstruction due to internal sources such as septal deviation, turbinate hypertrophy, or nasal lining abnormalities, and structural abnormalities such as nasal valve collapse or external nasal deformity. This approach, in categorizing each component of the nasal exam and its findings, allows the surgeon to formulate an appropriate treatment plan that emerges from the details of the examination.

Stair-Step Incision for Composite Grafts in Nasal Reconstruction.

Composite grafts are excellent options for treating external nasal deformities because they provide support and include the skin, which improves the delicate anatomy of the nose. However, they are constrained by size limits since the grafts rely on blood flow to the nasal bed. This is a critical issue when the recipient sites have scarring or degenerative diseases. A novel stair-step incision was made to produce a graft bed with a blood supply and to maximize the use of nonvascularized composite grafts. Instead of making a full-thickness defect through the skin envelope and lining, we placed individual incisions and connected them via a subcutaneous dissection. By dividing the defect into 2 layers, the graft bed was produced and the risk of fistula was reduced. From 2009 to 2020, we satisfactorily conducted 3 cases of nasal reconstruction with a stair-step incision followed by a composite tissue graft. One patient was a girl, and 2 were men. Their ages ranged from 11 to 44 years. The largest graft was 24 × 24mm in size. No complications were observed. The stair-step incision method for nasal reconstruction can eliminate the limitations of composite grafts and maximize improvements through a simple procedure. This makes composite grafts safer in cases with poor vascularity, enables larger composite grafts to survive, and lowers the risk of fistula formation by avoiding full-thickness defects.

Lateral Nasal Osteotomy

Purpose: To compare the external lateral nasal osteotomy with internal osteotomy in patients undergoing closed rhinoplasty with reference to intraoperative bleeding, duration of surgery, the ease of performing osteotomy, postoperative oedema, ecchymosis, and postsurgery esthetic satisfaction of patients. Materials and Methods: A total of 100 individuals of either sex with external nasal deformities were enrolled to the study and randomly allocated into two groups: Group I: Internal continuous osteotomy and Group II: External percutaneous perforating osteotomy. Data were collected and analyzed in terms of age and sex distribution, history of associated trauma, presence or absence of deviated nasal septum, presence of intraoperative bleed, the ease of performing each technique, duration of surgery, associated lid edema and ecchymosis, and final aesthetic correction. Results: External osteotomy is an easy approach to carry out and makes lateral osteotomy fracture lines with high precision. The damage to the nasal mucosa is much less. There is reduced bleeding, reduced edema and reduced ecchymosis around eyes. The postsurgery esthetic satisfaction is also higher among external osteotomy patients. Conclusion: The study concludes that external technique delivers a better and predictable control with precision to maximize the esthetic and functional results while limiting the potential for complication. It causes less tissue injury and provides higher confidence in being able to be performed. Moreover, the postsurgery esthetic satisfaction of Group II patients was higher, making it a preferable option for the surgeon and the patient as well.

Association Between Anterior Rhinoscopic/Endoscopic Assessment of Internal Nasal Valve and Various Nasal Deformities in the Rural Population of Vidarbha Region of India: A Cross-Sectional Study.

Background The nasal valves constitute the majority of the nasal cavity's resistance. Any reduction in this already narrow area can cause a significant reduction in the nasal airflow. In this present study, the aim was to do an endoscopic assessment of the internal nasal valve (INV) in patients with various nasal septal deviations, with or without external nasal deformity. We measured endoscopically the INV in various nasal deformities and derived its association with the INV on anterior rhinoscopy and endoscopic assessment. Method We included 75 patients in the study who were analyzed for angle and grade of the INV by anterior rhinoscopic examination and Hopkins rod zero-degree nasal endoscope (Karl Storz SE & Co., Tuttlingen, Germany). Nasal septal deviations were also studied with respect to the Mladina classification. Correlation between various nasal septal deviations with the INV was done. Since studies addressing the classification of INV are not available in the literature, for the purpose of simplification of observation of INV angle, (normal range 9-15 degrees), subjective stratification was made in the study, i.e.below 9, 9-15, and more than 15 degrees for the sake of knowing the underlying cause and its relationship. Result An anterior rhinoscopic examination was performed on 75 patients. INV Grade 1 was the most common, with 18 patients of (69.2%), 15 patients of DNS with caudal dislocation (55.6%), five patients of DNS with spur (38.5%), and four patients of DNS with external nasal deformity (50%). The next frequently observed Grade of INV on anterior rhinoscopy examination was Grade 2, in 11 patients of DNS with caudal dislocation (40.7%), four patients of DNS with spur (30.8%), and three patients of DNS with external deformity (37.5%), which was statistically significant in our study. In the majority of patients with all types of nasal septal deviations with or without external nasal deformity, INV (angle) of less than 9 degrees was noted, which was statistically significant. A linear relationship, ie., Grade 0 INV in Type I, Grade 1INV in types II, III, IV, and V, and Grade 2 in Type VII was observed. Our study is on par with the literature questioning the dogma of the normal angle of INV being 9-15 degrees. Conclusion We were able to establish a positive and complimentary role of anterior rhinoscopic and endoscopic assessment of INV. The proposed novel classification of the angle of INV by endoscopic assessment gives a better insight into the association of INV with various nasal septal deformities with or without external nasal septal deviation.

EUSTACHIAN TUBE DYSFUNCTION FOLLOWING ANTERIOR NASAL PACKING

Background: Eustachian tube maintains middle ear pressure equal to that of atmosphere and helps in ventilation of middle ear. Its function may be deranged due to adenoids, cleft palate, nasogastric tubes, allergy and by nasal packing. Objectives:To evaluate the effect of anterior nasal packing on Eustachian tube function. Methods: A cross-sectional study including 50 patients with deviated nasal septum with or without external nasal deformity and nasal polyposis. Tympanometry was performed prior to surgery, second post-operative day before pack removal and on seventh post-operative day ve days after pack removal. Results: Out of 50 patients (100 ears) who had anterior nasal packing after nasal surgeries, 40 ears had abnormal middle ear pressure after 48 hours of anterior nasal packing just before the pack removal. Middle ear pressure 5 days after the pack removal was found abnormal in 4 ears. Conclusion: This study shows that anterior nasal packing result in Eustachian tube dysfunction and negative middle ear pressure which is reversible in nature.

Are the sinonasal outcome test and nasal obstruction symptom evaluation scale questionnaires suitable for assessing the quality of life after septorhinoplasty? A prospective case-control study

In the evaluation after septorhinoplasty (SRP), the surgeon's plan and the patient's expectations may not always be realised. Therefore, in our prospective case-control study, we aimed to investigate whether the Sinonasal Outcome Test (SNOT-22) and Nasal Obstruction Symptom Evaluation Scales (NOSE), which have been validated in different patient populations in Turkish, are appropriate for evaluating SRP cases and their relationship with each other. Preoperative and postoperative data of NOSE and SNOT-22 questionnaires of 125 cases diagnosed with traumatic septum deviation and external nasal deformity and decided to be operated were analyzed. It was calculated that the SNOT-22 score of those with high/low preoperative NOSE scores was also high/low with a 53.6% probability and that the SNOT-22 score of those with high/low postoperative NOSE scores was also high/low with a 69.9% probability, indicating a positive and high-level relationship between postoperative NOSE and SNOT-22 measurements. When the answers given to all questions in SNOT-22 were evaluated separately, it was observed that the most disturbing symptoms of the cases were nasal obstruction at 78.4% and the need to blow the nose at 46.4% in the preoperative period, and nasal obstruction with 64.8% and the need to blow nose with 37.6% in the postoperative period. The most dramatic changes in the answers to SNOT-22 questions were observed in the patient's feelings of frustrated/restless/irritable, sadness, and embrassed. SNOT-22 and NOSE questionnaires can be used interchangeably to evaluate the functional status of patients undergoing SRP surgery.

Analysis of Imperative Facial Angles for Rhinoplasty: An Endowment to the Surgeon.

To study the nasal framework of patients in relation to CT scan and observe the Nasofrontal angle and Nasofacial angle in patients. This study is a prospective observational study. It was done from January 2020 to December 2020. It involved selection of patients with nasal complaints and external nasal deformity followed by their CT scan evaluation. It included a 3D analysis of the CT scan using a computer software. Preoperative photographic evaluation of the patient was done in frontal, lateral and basal view for a better understanding and correlation. Thirty patients were evaluated and their 3D reconstructed CT scans were observed. The mean Nasofrontal angle was 116.69°. The mean was 110.43° in males and 126.08° in females. The mean Nasofacial Angle was 37.68. The mean was 43.05° in males and 29.62° in females. There was a significant statistical difference seen. The demand for rhinoplasty in India is on rise. The studies done in the past have evaluated patients using plain 2D CT films. In this study, 3D reconstruction of CT scan has been done. There are meagre studies which describe the aesthetics of Indian population. It aids in preoperative evaluation and plan of surgery, enables a good doctor-patient communication. Also, it can be used for clinical learning of resident doctors.

Clinical analysis of 59 cases of pediatric nasal dermal sinus cysts with midfacial infection as the first symptom

Objective:To review the clinical and radiological presentation and management of infected nasal dermal sinus cysts（NDSC） in children. Methods:Clinical data were collected from 59 NDSC children with secondary fronto-orbital area infection who presented to Beijing Children's Hospital from January 2007 to December 2021. All patients underwent preoperative imaging workup, including MRI and CT. All patients underwent endoscopic excision of a NDSC under general anesthesia. Results:A total of 59 patients were included in the study,while 58 presented with a sinus, 1 presented with a cyst.The main lesions of NDSC included nasal root in 20 cases （33.9%）, nasal bridge in 34 cases （57.6%）, nasal tip in 4 cases （6.8%）, and nasal tip and nasal root in 1 case （1.7%）. The depth of lesions included 6 cases （10.2%） of superficial type of nasal frontal bone, 33 cases （55.9%） of nasal frontal bone, 19 cases （32.2%） of intracranial epidural type, and 1 case （1.7%） of intracranial epidural type. The main sites of infection included inner canthus in 15 cases （25.4%）, nasal dorsum in 22 cases （37.3%）, nasal root in 16 cases （27.1%）, and forehead in 6 cases （10.2%）. Among 59 cases, 7 cases （11.9%） were complicated with other diseases, and 4 cases（6.8%） had external nasal deformities. Surgical approaches included transverse incision in 12 cases（20.3%）, minimal midline vertical incision in 41 cases （69.5%）, external rhinoplasty in 4 cases （6.8%） and bicoronal incision with vertical incision in 2 cases （3.4%）. The range of lesions was completely consistent with MRI results.All cases were successfully operated without one-stage nasal dorsum reconstruction. All patients were followed up from 7 to 173 months（average 52.2 months）. There were 6 cases of recurrence, all of which were in situ recurrence. The operation was performed again, and no recurrence has occurred since the follow-up, No nasal deformity was noted, and cosmetic outcome were favorable for all patients. Conclusion:NDSC infection in children with midfacial infection as the first symptom is rare in clinical practice, and its manifestations are diverse. Early diagnosis and rational treatment are very important to improve the cure rate.Preoperative high resolution MRI combined with CT scanning is of great significance in judging the course of NDSC, especially the intracranial extension. The treatment goal is to achieve minimally invasive and individualized treatment under the premise of complete excision of the lesion, and take into account the cosmetic needs.

Concurrent management of nasal bone expansion from nasal polyposis (Woakes' disease).

BackgroundWoakes' disease is the eponymous name for severe chronic rhinosinusitis with nasal polyposis (CRSwNP) leading to thinning and expansion of the nasal pyramid. The endoscopic treatment of the sinus disease, while extensive, is standard practice for the rhinologist. Management of their external nasal deformities, for many, is not. Simultaneous closed rhinoplasty in these patients is straightforward, easy to perform and achieves an excellent esthetic outcome.MethodsThree patients with CRSwNP and notable nasal pyramid expansion are reviewed. All patients had eosinophilic disease, with two having NSAID‐exacerbated respiratory disease (N‐ERD). All three patients underwent full house endoscopic sinus surgery from May 2018 to September 2019 along with simultaneous closed rhinoplasty. Two of these patients required only external digital pressure to fracture the nasal bones for gentle Boies elevator repositioning, while the third had osteotomies with minimal force to aid reduction.ResultsPostoperatively, patients had excellent nasal airway symptom improvement, and the cosmetic results following rhinoplasty demonstrated normalization of symmetry, profile, and contour of the nose with high‐patient satisfaction.ConclusionBased on our experience, simultaneous rhinoplasty on the thinned nasal bones of Woakes' Disease patients is not only easy to perform, but provides excellent cosmetic and functional results by allowing bone to remodel in the appropriate position, and avoids a second‐stage rhinoplasty.

Optimizing Quality of Life and Minimizing Morbidity through Nasal Preservation in Endoscopic Skull Base Surgery: A Contemporary Review.

Introduction Endoscopic endonasal approaches (EEAs) are increasingly utilized for intracranial pathology. As opposed to sinonasal tumors, the nasal cavity is being used as a corridor to access these intracranial tumors but is not the site of primary surgical intent. Accordingly, there has been recent interest in preserving intranasal structures not directly involved by tumor and improving postoperative sinonasal quality of life (QOL). Objectives The aim of the study is to highlight recent advances in EEA techniques focused on improving sinonasal QOL including turbinate preservation, reducing the morbidity of reconstructive techniques, and the development of alternative minimally invasive EEA corridors. Methods The method of the study involves contemporary literature review and summary of implications for clinical practice. Results Nasoseptal flap (NSF) harvest is associated with significant morbidity including septal perforation, prolonged nasal crusting, and external nasal deformities. Various grafting and local rotational flaps have demonstrated the ability to significantly limit donor site morbidity. Free mucosal grafts have re-emerged as a reliable reconstructive option for sellar defects with an excellent sinonasal morbidity profile. Middle turbinate preservation is achievable in most EEA cases and has not been shown to cause postoperative obstructive sinusitis. Recently developed minimally invasive EEA techniques such as the superior ethmoidal approach have been described to better preserve intranasal structures while allowing intracranial access to resect skull base tumors and have shown promising sinonasal QOL results. Conclusion This contemporary review discusses balancing effective skull base reconstructive techniques with associated morbidity, the role of turbinate preservation in EEA, and the development of unique EEA techniques that allow for increased nasal structure preservation.

A Case of Traumatic Nasal Valve Stenosis Successfully Treated with Open Rhinoplasty and Z-Plasty.

External nasal deformity is common and can be treated surgically. It often occurs in conjunction with the development of the nasal septal cartilage, vomer, and vertical plate of the ethmoid bone but may be caused by trauma. Here, we present a case of external nasal deformity caused by trauma. A woman presented with nasal obstruction due to dysfunction of the nasal valve area and was referred to our department for treatment. No chronic rhinosinusitis or nasal septal deviation that causes nasal obstruction was noted at the initial examination. However, trauma-related scarring was observed in the nasal valve area, and a Cottle test yielded positive results. The patient underwent combined rhino- and Z-plasty surgery and is currently undergoing follow-up at an outpatient clinic.Although otolaryngologists generally use an endonasal approach to treat nasal obstruction, it is important to perform an appropriate evaluation of the external nose and to collaborate with a plastic surgeon, as necessary.

Septorhinoplasty-our experience

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; The nose is not only a vital organ but also cosmetically important, especially for younger individuals. External nasal deformities like deviated nose, crooked nose, hump deformity, abnormalities of the tip are more noticeable. They cause cosmetic disfigurement and also may cause nasal obstruction when associated with deviated nasal septum. One of the oldest known cosmetic surgeries is rhinoplasty. Septorhinoplasty is done to correct the deviated septum as well as the external deformity of the nose. The aim is to study the indications, various surgical methods used, complications and results of septorhinoplasty.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 30 patients were taken into the study based on the inclusion and exclusion criteria. They underwent rhinoplasty surgeries based on different deformities.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; The majority of the patients were in the 21-30 years age group and deviated nasal septum with external deformity was the most common pathology addressed. Septal cartilage was used as the graft material in most cases. Excessive bleeding was the most common complication encountered and all the patients were satisfied with the result.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Septorhinoplasty can be done for functional as well as cosmetic causes. Graft material should be chosen based upon the defect to be corrected. The results depend upon the defect and the expertise of the surgeon.&lt;/p&gt;

Assessment of Functional and Esthetic Outcomes of External Approach Septorhinoplasty with Spreader Graft in North India

Introduction: Rhinoplasty is one of the most commonly performed facial plastic surgeries. Esthetic rhinoplasty can be exclusively esthetic or for both functional and esthetic concerns combined. The spreader graft can be used as a spacer where a patient with nasal obstruction who is also having external nasal deformity can be benefitted in both the areas. Objectives: The objective is to assess the functional and esthetic outcomes pre- and post-operatively in patients undergoing external approach rhinoplasty with spreader grafting. Methodology: Thirty patients were included in the study. Internal valve collapse was confirmed by modified Cottle's maneuver and diagnostic nasal endoscopy. All surgeries were done using an external approach under general anesthesia. Pre- and post-operative nasal obstruction symptom evaluation (NOSE) and rhinoplasty outcome evaluation (ROE) score were taken. Results: The preoperative NOSE score average was 64.5. After 3 months of postoperative follow-up, the NOSE score reduced to a mean value of 11.83. The preoperative ROE score average was 6.73. Postoperative ROE score improved to a mean value of 18.83. Conclusion: Rhinoplasty is a delicate, skill demanding surgical procedure which, when done along with a spreader graft will be beneficial both functionally and cosmetically in patients with external nasal deformity with obstruction symptoms. Comparison of esthetic and functional results could be done further in future studies which will provide further inputs in the field of rhinoplasty.

Nasal Septal Deviation in Relation to External Nasal Deformities: An Observational Study

Nasal Septal Deviation in Relation to External Nasal Deformities: An Observational Study

A Study of Nasal Septal Deviation, External Nasal Deformities, and their Correlation with the Severity of Sino-Nasal Symptoms Using Sino Nasal Symptoms Score Questionnaire

Background/Rationale: The human nose is structurally complex and this complexity results in nasal shape and shape variations. Midline deformities such as hump nose, saddle nose, tip deformities and lateral nasal deformities such as crooked nose, deviated nose, alar depression are common forms of deformity affecting the external nose. Internal nasal valve (INV) is a key anatomical landmark of nasal cavity. Any obstructions in this region have tremendous effects on inspiratory and expiratory currents. This study aims to assess the nasal septal deviation and external nasal deformities and correlate the severity of sino nasal symptoms.&#x0D; Methods: This Prospective observational study will include total 50 patients with nasal septal deviation. Patients will undertake Sino Nasal Test -22 questionnaire. Investigations like Diagnostic nasal endoscopy with 30 degree nasal endoscope, X-ray PNS Water’s view and complete blood count including absolute eosinophilic count will be carried out. Data will be analysed using appropriate statistical tests.&#x0D; Expected Results: A significant correlation is expected between Nasal Septal Deviation, External Nasal Deformities, and Severity of Sino-nasal Symptoms.&#x0D; Conclusion: This study will reflect on internal nasal valve and it’s correlation with etiopathological process of upper respiratory tract. It will also guide clinicians in choosing appropriate surgical approach.

Diagnostic accuracy of physical examination findings for midfacial and mandibular fractures

ObjectivesTo assess the diagnostic accuracy of physical examination findings used to identify patients at risk for midfacial or mandibular fractures. Materials and MethodsA five-year retrospective cohort was constructed from all emergency department patients with a midfacial or mandibular trauma. The sensitivity, specificity, pre-test probability, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio data was calculated for 19 and 14 physical examination findings for midfacial and mandibular fractures respectively. Computed Tomography and panoramic radiography were used as index tests. ResultsA total of 1484 patients were identified among whom 40.4% midfacial and 33.4% mandibular fractures were diagnosed. Overall, specificity was found to be higher than sensitivity. Regarding midfacial fractures, high specificity was found for raccoon eyes, malar eminence flattening and all the findings that are related to palpation, the nasal, ocular and intra-oral assessment. Malar eminence flattening, external nasal deformity, nasal septum hematoma, change of globe position and palpable step-off had ad high positive predictive value and positive likelihood ratio. Regarding mandibular fractures high specificity was found for mouth opening restriction, auditory canal bleeding, intra-oral assessment related findings, palpable step-off, inferior alveolar nerve paresthesia, the angular compression test and chin axial pressure test. ConclusionsThe diagnostic accuracy of relevant physical examination findings were identified for the prediction of midfacial and mandibular fractures.

816 A Case of obstructive Sleep Apnea in an Adolescent girl with crouzon syndrome

Abstract Introduction Crouzon syndrome is an autosomal dominant type of craniosynostosis, first reported by French neurologist Octave Crouzon in 1912. Craniosynostosis refers to the premature closure of cranial sutures. The orofacial manifestations of this syndrome includes maxillary hypoplasia, external nasal deformity and prognathism, which can all contribute to breathing difficulties. The prevalence of Obstructive Sleep Apnea (OSA) is above 60%. The severity of obstruction can be life threatening prompting early surgical intervention ranging from tracheostomy to mid facial distraction like LeFort III osteotomy. Report of case(s): An 18-year-old girl with Crouzon syndrome, who was referred for snoring. She had a significant past surgical history of craniotomy and ventricular-peritoneal shunt at the age of 2 years, tracheostomy dependency until the age of 5 years after undergoing a LeFort III osteotomy, and adeno-tonsillectomy at 6 years. She had never had a polysomnography (PSG) before. Her in-lab PSG showed moderate to severe OSA with an Apnea-Hypopnea Index (AHI) of 28.5/hr. She had no central apneas. Obstructive events were not controlled with Continuous Positive Airway Pressure (CPAP), but did respond to Bi-level therapy. Plastic Surgery favored a repeat LeFort III osteotomy and cranioplasty instead. A post-surgical PSG showed resolution of OSA with an AHI of 2.8/hr. Conclusion This case reminds us that patients with craniofacial abnormalities are at higher risk for OSA and are more difficult to treat. Our patient had significant sleep apnea despite prior surgical interventions. Patients with Crouzon syndrome should be studied for OSA, and re-assessed over time. Her repeat surgery had a positive outcome, and avoided PAP therapy. Therefore, Plastic Surgery should always be part of the therapeutic discussion. Support (if any) 1. Samuel N, Arvind B, Sameep K and Eugene M (2014) Revisiting Crouzon syndrome: reviewing the background and management of a multifaceted disease. 2. J Sirotnak 1, L Brodsky, M Pizzuto (1995) Airway obstruction in the Crouzon syndrome: case report and review of the literature. 3. Mitsukawa N, Satoh K, Hayashi T, Furukawa Y, Uemura T (2004) A reflectable case of obstructive sleep apnea in an infant with Crouzon syndrome.