External Nasal Research Articles

Exit point of the external nasal nerve- cadaveric study

This study aims to confirm how the external nasal nerve exits from the internal surface of the nasal bone to the dorsum of the nose and to determine the exact point of nerve emergence by macroscopic examination. Twenty external nasal nerves of both sexes from the elderly and adult age groups were dissected. The exit point of the external nasal nerve, the width of the nasocartilaginous joint, and the inferior border of the nasal bone from the midline to the nasomaxillary suture were measured. The nerve was classified according to its branching pattern. In this study, in the elderly group, the external nasal nerve enters the dorsum of the nose through the pyriform ligament and exits laterally to the nasocartilaginous joint. But in the adult age group the external nasal nerve exits between the nasal bone and the upper nasal cartilage. We observed mainly three types of nerve but did not find any subtypes or variations in the branching pattern. Among this main classification of nerves, more cases (70%) of type I were observed. However, based on our study, we concluded that the external nasal nerve enters the dorsum of the nose either between the nasal bone and the upper nasal cartilage, or it passes through the pyriform ligament and exits lateral to the nasocartilaginous joint. In rhinoplasty, knowledge about the course, exit point, branching pattern, and variations of the external nasal nerve is unavoidable.

Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies.

The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability. Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001). These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.

Distribution patterns of infraorbital nerve branches and risk for injury

BackgroundDuring oral and head and neck surgery, oral vestibular incisions may require a transverse incision on the upper lip mucosa, resulting in possible sensory disturbances in the area innervated by infraorbital nerve (ION) branches. Although sensory disturbances are attributed to nerve injuries, anatomy textbooks have not showed the precise distribution patterns of the ION branches in the upper lip. Furthermore, no detailed study has been available on this issue. This study aimed to reveal the precise distribution patterns of ION branches in the upper lip by dissecting the detached upper lip and cheek area using a stereomicroscope. MethodsDuring a gross anatomy course at Niigata University (2021–2022), nine human cadavers were examined with special focus on the relationship between ION branches in the upper lip and the layered structure of facial muscles. ResultsThe ION branched to the inferior palpebral (IP), external and internal nasal, and superior labial (lateral and medial) nerves. The ION branches in the upper lip did not run in a horizontal pattern from outside to inside but showed a predominantly vertical pattern. Considering their course, incising the upper lip mucosa transversely may cause paresthesia of the ION branches. The internal nasal (IN) and medial superior labial (SLm) branches tended to penetrate the orbicularis oris and descend between this muscle and labial glands, whereas the lateral superior labial (SLl) branches tended to innervate the skin. ConclusionsThese findings suggest that a lateral mucosal incision is recommended for oral vestibular incisions of the upper lip and that deeper incisions to the labial glands should be avoided when incising the medial side to preserve the ION during surgery from an anatomical point of view.

Anatomical Comparative Study of the External Nasal Nerve in Caucasian and Asian: Application for Minimizing Nerve Damage in Rhinoplasty

BackgroundThe numbness of the nasal tip is the main symptom of the external nasal nerve injury, especially after rhinoplasty. This postoperative syndrome can reduce the patient’s satisfaction with the operation. Having a better understanding of the anatomical structure and intraoperative protection can effectively avoid nerve injury. At present, the anatomical research on this nerve is all from Asia. This study aims to fill the gap in the anatomical study of this nerve in Caucasians and provides comparative results with Asians.Material and MethodsA total of 20 Caucasian cadavers were embalmed using the Thiel method. On dissection, after complete exposure of the external nasal nerves, the distance between the exit point of the external nasal nerve and the nasal midline was measured, and the morphology of the nerves was compared with the Asian data. The nerves were classified into types based on their branching pattern.ResultsThe nerve plane was the same as the Asian record. The distance ranged from 5.08 to 11.94 mm (mean, 8.31 ± 1.85 mm). This distance has statistical significant difference compared with the Asian population (P < 0.01). The average distance is larger, and the distribution range of the exit point is wider. On classification, 35 of 40 cases had the same type results as those previously reported, with the primary types I, II and III. Five new varieties were found which are classified as subtypes of the primary types and a new type IV. Furthermore, the bifurcation position in two-thirds of the type II cases and variations is proximal to that seen in the Asian population.ConclusionsThe anatomical structure of the external nasal nerve in Caucasians and Asians has obvious differences. This nerve in Caucasians is more likely to be damaged during rhinoplasty than Asians. Except the primary types, the classification of the external nasal nerve also includes subtypes and type IV.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Pediatric nasal neuroglial heterotopia: report of 13 cases

Objective: To summarize clinical features and our experience of the diagnosis and treatment of pediatric nasal neuroglial heterotopia (NGH). Methods: Clinical data of 13 nasal NGH patients in Beijing Children's Hospital from August 2014 to October 2019 were retrospectively reviewed, including 9 boys and 4 girls, aged from 1 to 38 months with median age of 5 months. Radiological workups and excision of nasal NGH under general anesthesia were performed for all patients. B ultra-sound and MRI were performed for all external and mixed lesions, while ultra-low-dose CT scan and MRI for all intranasal type. Surgical approaches were dependent on location and extent of the lesions according to radiographic workup, including extranasal or transnasal endoscopic approach. Patients were followed up regularly after operation to evaluate the effect. Initial presentation, locations, imaging findings, surgical approaches and follow-up results were analyzed through descriptive statistical method. Results: Eight nasal NGH patients presented with an internal nasal mass and nasal obstruction, which belonged to intranasal type. Three patients presented with an external nasal mass which belonged to extranasal type and 2 patients had mixed lesions. The sites included nasal dorsum (n=5), anterior to the middle turbinate (n=5) and olfactory cleft (n=3). Surgical resections were done through median rhinotomy approach (n=5) or transnasal endoscopic approach (n=8). All the operations were successful and no complication occurred. All cases were followed up from 3 to 65 months. No recurrence was encountered. Conclusions: Nasal NGH is a rare lesion with atypical clinical presentation. Preoperative imaging including CT scan and MRI is essential for evaluation of the location, extent of the disease and for making the surgical plan. Treatment requires complete surgical excision.

The role of an internal nasal dilator in athletes.

The nasal valve area has the minimal cross-sectional area of the upper airways. Nasal dilators have been found able to improve sport performance in athletes. The aim of this study was to investigate whether the use an internal nasal dilator may be able to affect respiratory pattern in a group of athletes. The use of internal nasal dilator induced a significant reduction of fatigue perception (p=0.000) and was optimally accepted. In conclusion, the present study demonstrates that Nas-air® is an internal nasal dilator able to reduce the fatigue perception and is preferred to external nasal dilator. (www.actabiomedica.it)

Relevance between the facial morphology and nasal index: analysis of 210 young Han women in Henan

Objective To investigate the relationship between the facial morphology and the nasal shape for young women of Han nationality in Henan. Methods Aiming at the female conscripts in Henan province in 2016, 210 healthy young females were enrolled in this study, and their anthropometric features were measured including height, weight, total head height, physiognomic facial height, morphological facial height, upper lip height, lip height, facial width, mandibular width, mouth breadth, nasal height, nasal length, nasal depth, and width of nose. The nasal indexes were divided into 5 groups according to different facial types. And their mean and standard deviation were calculated. The differences were analyzed by SPSS version 21.0. Results Among the indexes measured, there were significant differences in height, face height, shape face height, upper lip height, face width, mandibular width, head height/face width, face height/face width, shape face height/face width and nose index; P values were significant. The classification of facial types was based on the ratio of morphological surface index to area width, and the main types of the groups were mid-facial and narrow-facial types. The differences among different facial types were statistically significant (F=12.75, P<0.05). The scatter plot showed that there was a linear correlation between nasal index and facial shape. Linear regression analysis showed that the linear equation Y=135.84-75.5X (X is the ratio of morphological index to facial width, Y is the nasal index). Conclusions Nasal type is related to the face type. The linear fitting equation between morphological facial height/facial width and nasal index is Y=135.84-75.5x. These findings may enrich the external nasal database, provide reference for the correction of nasal deformity and nasal reconstruction, and direct the clinical therapy. Key words: Face; Nose; Body measurement; Han nationality; Women; Henan

Efficacy of external nasal nerve block following nasal surgery : Arandomized, controlled trial.

Pain is the major determinant factor which affects the quality of recovery and postoperative agitation following nasal surgery with the patient under general anesthesia. Our objectives were to test the hypothesis that an external nasal nerve block will decrease pain intensity, decrease drug consumption, decrease the incidence of postoperative emergence agitation and improve quality of recovery. In this study 100 adult patients who were scheduled for elective external nasal surgery with the patient under general anesthesia and nasal packing on each side, received external nasal nerve blocks postoperatively for 24 h with saline (groupI) or 2% xylocaine (groupII) with 1:200,000 epinephrine. Postoperative pain was measured at the postanesthesia care unit (PACU) utilizing a visual analog scale (VAS). Narcotics consumption was also measured. Emergence agitation and quality of recovery were also assessed. Pain scores were statistically significant between both groups. Requirements of equivalent morphine doses in the PACU were lower in groupII (block) than groupI (control) with a significant Pvalue <0.001. GroupII (block) patients required significantly less intraoperative fentanyl than groupI (control) patients (p = 0.001). GroupII (block) showed higher scores in pain dimension of QoR-40 in comparison with groupI (P<0.001). The incidence of emergence agitation was lower in groupII (block) than in groupI (control, 24% vs. 48%, P = 0.012). External nasal nerve block is an effective technique for reducing postoperative pain, drug consumption and quality of recovery. It also reduces emergence agitation. The effects are mainly due to profound analgesia and effective pain control that lead to decreased drug usage and reduced discomfort.

A retrospective review of 46 cases of chronic invasive fungal rhinosinusitis

Objective To investigate the clinical characteristics of chronic invasive fungal rhinosinusitis. Methods Clinical features and outcomes of 46 proven cases of chronic invasive fungal rhinosinusitis admitted in Huashan Hospital, Fudan University from January 2009 to December 2016 were retrospectively reviewed. Results Of the 46 patients enrolled, left sphenoid sinus, ethmoid sinus and maxillary sinus were affected in 24, 23 and 20 cases, respectively, while right maxillary sinus, ethmoid sinus and sphenoid sinus were affected in 18, 16 and 15 cases, respectively. Left and right frontal sinus were affected in 9 and 6 cases, respectively. The central nervous system and orbit were the most commonly affected sites in external nasal involvements, noted in 22 cases respectively. Left sphenoid (17 cases) and ethmoid sinus (15 cases) involvements were most common in central nervous system affected patients. Left sphenoid (14 cases) and ethmoid sinus (13 cases) involvements were most common in orbit affected patients. Aspergillus species were the primary pathogens observed in 42 cases. Zygomycete, candida and dark filamentous fungus were observed in two, one and one case, respectively. Pathologically, 37 of the cases were chronic nongranulomatous type and the left 9 were chronic granulomatous type who were all immunocompetent hosts. The initial symptoms usually included headache, dizziness and nasal discomforts including nasal obstruction and purulent secretion. The chief complaints usually included headache, dizziness, and visual disturbances including blurred vision, vision loss or even blindness. Antifungal treatment combined with surgical interventions for removal or drainage focus lesions achieved significant effect, and 42 patients were cured. Conclusions Chronic invasive fungal rhinosinusitis should be taken into consideration in the presence of nasal discomforts or nonspecific symptoms such as headache and dizziness. The possibility of chronic invasive fungal rhinosinusitis should be cautious after the emergence of vision abnormalities. Key words: Chronic; Fungal rhinosinusitis; Clinical characteristics; Treatment

Variant Anatomy of the Nasal and Labial Branches of the Infraorbital Nerve.

Comprehensive understanding of the variations in the branches of the infraorbital nerve (ION) is vital to the prevention of iatrogenic nerve injury and successful ION blockade during orbitozygomatic facial procedures. Only a few studies exist on the variant anatomy of the branching patterns of this nerve. This article provides a detailed description of the variations of the nasal and superior labial branches of the ION. This study was performed on 84 IONs by dissecting 42 formalin-fixed cadavers from the Laboratory of Topographic Anatomy, Department of Human Anatomy, University of Nairobi. The branches were exposed at their origin and followed to their termination. The findings included variant emergence patterns, anomalous course, and absence as well as extra branches. It was noted that the external nasal nerve was absent in 34.53% cases. There were common trunks between the internal and external nasal nerves and cases of communication between branches of these nerves were also noted. Accessory superior labial nerves were present in 9.52% of the nerves. This detailed study reveals additional variations in the emergence and branching pattern of the ION. Caution is imperative during orbitozygomatic facial surgery to prevent injury to these branches. These variations also underlie the lack of response to surgical treatment for trigeminal neuralgia and also the need for a filtration to achieve full anesthesia after ION block. In addition, the extra branches identified raise the prospects of using these nerves for grafting purposes if their precise patterns are determined.

A twin-center study of nasal tip numbness following septorhinoplasty or rhinoplasty.

Nasal tip numbness is a recognized postoperative complication after septorhinoplasty and rhinoplasty. We performed a twin-center retrospective study to determine the incidence of short- and long-term (>6 mo) nasal tip numbness after these procedures, and we studied several variables that might have been associated with this complication. Our study group was made up of 65 patients-31 males and 34 females, aged 15 to 67 years (mean: 30.5). Septorhinoplasty had been performed in 52 patients and rhinoplasty in 13; all surgeries were performed by two different surgeons at two different centers. There were 50 closed (endonasal) surgeries and 15 open surgeries. Follow-up phone calls made 6 to 37 months postoperatively revealed that 17 patients had experienced postoperative nasal tip numbness (26.2%); there were 10 cases of short-term numbness (15.4%) and 7 cases of long-term numbness (10.8%). Numbness resolved within 2 weeks in 8 of the 10 short-term patients. Of the 7 cases of long-term numbness, 6 patients reported severe numbness beyond 8 months, and 1 had mild numbness for at least a year. We found no association between the incidence of numbness and the type of surgery, the particular surgeon, or the particular center where the surgery had been performed. We did find that there was an association between long-term numbness and the open procedure, but it was not statistically significant. We discuss the possible mechanisms that might cause numbness in cases when the external nasal nerve is not cut. We believe it is important to include a discussion of the risk of nasal tip numbness during preoperative consultations and when seeking informed consent.

External Nasal Neuralgia: A Neuropathic Pain Within the Territory of the External Nasal Nerve

Nasal pain is a challenging diagnosis and very little has been reported in the neurological literature. The nose is a sophisticated structure regarding its innervation, which is supplied by the first and second divisions of the trigeminal nerve. Painful cranial neuropathies are an important group in the differential diagnosis, although they have been described only scarcely. Here, we report a case that can conform a non-traumatic external nasal nerve neuralgia. A 76-year-old woman was referred to our office due to pain in her left nose. She was suffering from daily excruciating attacks, which were strictly limited to the territory supplied by her left external nasal nerve (left ala nasi and apex nasi). She denied previous traumatisms and the ancillary tests did not yield any underlying pathology. An anesthetic blockade of her left external nasal nerve achieved a marked reduction of the number of episodes as well as their intensity. External nasal neuralgia seems a specific neuralgia causing nasal pain. Anesthetic blockades of the external nasal nerve may be a valid treatment for this condition.

The Sihler staining study of the infraorbital nerve and its clinical complication.

The infraorbital nerve (ION) is a cardinal cutaneous nerve that provides general sensation to the mid face. Its twigs are vulnerable to iatrogenic damage during medical and dental manipulations. The aims of this study were to elucidate the distribution pattern of the ION and thus help to prevent nerve damage during medical procedures and to enable accurate prognostic evaluation where complications do occur. This was achieved by treating 7 human hemifaces with the Sihler modified staining protocol, which enables clear visualization of the course and distribution of nerves without the accidental displacement of these structures that can occur during classic dissection. The twigs of the ION can be classified into the usual 5 groups: inferior palpebral, innervating the lower eyelid in a fan-shaped area; external and internal nasal, reaching the nosewing and philtrum including the septal area between the nostrils, respectively; as well as medial and lateral superior labial, supplying the superior labial area from the midline to the mouth corner. Of particular note, the superior labial twigs fully innervated the infraorbital triangle formed by the infraorbital foramen, the most lateral point of the nosewing, and the mouth corner. In the superior 3-quarter area, the ION twigs made anastomoses with the buccal branches of the facial nerve, forming an infraorbital nervous plexus. The infraorbital triangle may be considered a dangerous zone with respect to the risk for iatrogenic complications associated with the various medical interventions such as implant placement.

Measurements and characteristics of external nose-related parameters in normal Uygur people

Objective To measure and analyze the external nasal morphology of normal Uygur in Xinjiang,which will provide the anatomical basis for the rhinoplasty.Methods From the Department of Otolaryngology and Plastic Surgery of our hospital,we collected the Uighur patients' families as the research objects during January 2011 to December 2012,and at the same time Han nationality patients' families were set as control group.Related parameters of external nose measurements were completed,and the parameters of external nose of 95％ confidence interval calculated,and compared with those of Han people.Results The measured data showed that there were the 95％ confidence interval of the Uighurs external nasal related indicators; The nasal length,height,depth,dorsum slope length,temples,nasal tip angle of the male Uighur were greater than those of male Han; Uighur women had longer,higher nose,more slope length of the nose back,and greater nasal-facial angle and nosewing angle than that of Han women.The proportion of ultra narrow nasal type,narrow nose,the middle nose in Uighur men was 14.02％,79.50％,and 6.48％ ; that in Uighur women was 14.60％,67.72％,and 17.68％,respectively; compared with those in Han nationality,there was a significantly statistical difference (P＜0.05).Conclusions The external nasal morphology of the Uygur people in Xinjiang has its characteristics,with dominants of narrow nasal type; 95％ of medical reference range will provide an objective reference basis for the future clinical work. Key words: External nose; Uygur; Measurement

Variations in emergence and course of the inferior palpebral nerve.

Comprehensive understanding of the anatomy of the inferior palpebral (IP) nerve is crucial to preservation of sensation in the inferior eyelid and conjunctiva. Iatrogenic injuries may occur during blepharoplasty, repair of orbitozygomatic fracture and other maxillofacial surgeries involving this region. Although several studies depict the anatomical variations of the main infraorbital nerve (ION), little information exclusive to the IP nerve exists. This study provides information on the additional variations of the ION with reference to the IP nerve. The study was performed on 84 IP nerves by dissection of 42 formalin-fixed cadavers from the laboratory of topographic anatomy, Department of Human Anatomy, University of Nairobi, Kenya. Each of the nerves were exposed at the emergence and followed to their termination. Variations encountered involved emergence, course, and even absence. Variant emergence was through an accessory infraorbital foramen, an infraorbital notch, and as a common trunk with the external nasal nerve. This nerve shows high anatomical variability that may account for the difficulties and complications encountered in clinical interventions. It is believed that this information will improve clinical management of conditions affecting the region of distribution of the IP nerve.

Comparing the Alteration of Nasal Tip Sensibility and Sensory Recovery Time following Open Rhinoplasty with and without Soft Tissue Removal

In this study we evaluated sensory alteration in nasal tip and adjacent upper columella (territory of external nasal nerve) after open rhinoplasty. Two groups were randomly selected, each containing 25 patients with thick nasal skin; sensory testing was done preoperatively in all patients; in group one, subdermal soft tissue in tip and supratip areas was removed but in group two no soft tissue removal was done; we compared sensory pressure threshold values 3 weeks and 6 months postoperatively. Results showed no statistical difference between the two groups in nasal skin sensibility at these times; also this study showed that 6 months after rhinoplasty normal sensation of nasal skin will be achieved.

Autopsy study for maxillary nerve and its artery supply

To observe the travel, divisions, and the lengths, diameters, branches, artery supplies of the main segments of maxillary nerve. Fifty formalin-preserved adult half-head specimens with intravascular injection of red color emulsion were used for the gross and microanatomical studies of maxillary nerve. The lengths, diameters, branches and artery supplies of four main segments of maxillary nerve were observed. SPSS 11.5 software was used to analyze the data. The length and diameter of cranial middle fossa segment of maxillary nerve were (10.70 ± 1.31) mm and (4.01 ± 0.52) mm respectively, which was supplied by inferior-lateral cavernous sinus artery. The length and diameter of pterygopalatine fossa segment were (16.21 ± 1.80) mm and (3.27 ± 0.62) mm respectively, in which one zygomatic branch, one to three posterior superior alveolar nerves, two ganglion branches and tuberal descending branches; were given off, and the segment was supplied by foramen rotundum artery. The length and diameter of infraorbital segment were (25.73 ± 2.03) mm and (3.30 ± 0.52) mm and it gave off middle superior alveolar nerve (64%) and anterior superior alveolar nerve and was supplied by infraorbital artery. Facial segment gave off superior labial branches, internal and external nasal branches, inferior palpebral branches, buccal branch and zygomatic branch and these branches were supplied by infraorbital artery and superior labial and angular artery originating from facial artery. Understanding of travel and artery supply of maxillary nerve is helpful to regional anaesthesia and surgery for maxillary nerve. Foramen rotundum, sphenopalatine foramen and infraorbital nerve are important marks for endoscopic surgery in pterygopalatine fossa.

Combined Use of Infraorbital and External Nasal Nerve Blocks for Effective Perioperative Pain Control during and after Cleft Lip Repair

Perioperative analgesia in patients undergoing cleft lip and palate repair is complicated by the risk of postoperative airway obstruction. We describe a technique of combined infraorbital and external nasal nerve blocks to reduce the need for opioid analgesia. Using this technique, we have successfully performed cleft lip repair under local anesthesia alone, without general anesthesia or intravenous sedation, in adolescents and adults. In children, this technique can reduce the need for postoperative opioids. We describe this novel analgesic approach to decrease opioid requirements and minimize perioperative risk.

Post‐Traumatic External Nasal Pain Syndrome (a Trigeminal Based Pain Disorder)

Little has been written about persistent external nasal pain after injury to the nose in the neurologic or headache literature. In clinical practice, this can be a disabling and treatment refractory condition. The external portion of the nose is highly innervated by branches of the ophthalmic and maxillary divisions of the trigeminal nerve including the nasociliary nerve, external nasal nerve, infratrochlear nerve, anterior ethmoidal nerve, and infraorbital nerve. As these nerves are located on the external portion of the nose just deep enough to the skin they can be easily traumatized with any impact to the nose. Four patients with what is termed the post-traumatic external nasal pain syndrome are reported in this paper, describing the clinical presentation of the disorder and providing treatment options. Post-traumatic external nasal pain syndrome appears to be a novel form of trigeminal-based pain not previously reported in the neurologic literature.

Combined Use of Infraorbital and External Nasal Nerve Blocks for Effective Perioperative Pain Control during and after Cleft Lip Repair

Combined Use of Infraorbital and External Nasal Nerve Blocks for Effective Perioperative Pain Control during and after Cleft Lip Repair