Nasal Aperture Research Articles

Congenital nasal pyriform aperture stenosis: report of two cases

Congenital nasal pyriform aperture stenosis is a rare cause for congenital nasal obstruction. There are few publications about this severe condition. We report two cases of newborns diagnosed with congenital nasal pyriform aperture stenosis submitted to surgical treatment. Both had respiratory difficulty since birth, represented clinically by the difficulty during breastfeeding. No concomitant comorbidities were identified. The first patient underwent early surgical treatment, as she presented with severe respiratory distress. The second patient had failed conservative treatment and was also subjected to the surgical widening of the pyriform aperture. Both patients evolved uneventfully in the postoperative period. Congenital nasal pyriform aperture stenosis is part of the differential diagnosis of congenital nasal obstruction, being choanal atresia the most common finding. Its clinical presentation can vary from mild respiratory distress, which only disables breastfeeding, to respiratory failure at rest. As it is a rare occurrence, with few publications, its management is still controversial. The need for surgical management in both reported cases and a favorable evolution are highlighted, allowing hospital discharge and adequate breastfeeding. Level of evidence: Level V, therapeutic study.

Utilising the nasal aperture for template stabilisation for guided surgery in the atrophic maxilla

BackgroundTemplates aim to facilitate implant placement in the prosthetically preferred position. Mucosa-supported and bone-supported templates are commonly used in the edentulous maxilla. In the atrophic maxilla (Cawood V and VI), however, these templates can be easily displaced due to a lack of supportive tissues, even in cases where anterior sites offer sufficient bone for implant placement. To assist in positioning and stabilisation, we designed a template that utilises the nasal aperture as a fulcrum to create a forced and exclusive fit. The aim of this study was to assess the clinical usability of the developed template and the corresponding implant placement accuracy in patients with edentulous atrophic maxillae. Deviations between planned and placed implant positions were measured by aligning pre- and post-operative cone beam computed tomography scans.ResultsTwenty-four implants were placed in 11 patients. One template did not fit properly due to a slight undercut. All implants could be placed with good primary stability. The implants had high accuracy at the implant shoulder (global deviation 1.1 ± 0.5 mm, lateral deviation 0.8 ± 0.5 mm) and a mean angular deviation of 7.2 ± 3.4°.ConclusionsThe developed surgical template offers stabilised and secure template placement in the edentulous atrophic maxilla, resulting in satisfying implant placement accuracy when using a semi-guided approach.Trial registrationNetherlands Trial Register, NL6561, registered 26 September 2017.

Congenital nasal pyriform aperture stenosis: a rare condition treated successfully by expectant managemen

Congenital nasal pyriform aperture stenosis: a rare condition treated successfully by expectant managemen

Evaluating the morphological and metric sex of human crania using 3-dimensional (3D) technology.

Identifying the skeletal remains of an unidentified individual is a priority for the medico-legal system because identification increases the chances of finding the person responsible and provides closure to the family. The purpose of this research was to develop a combined morphological and metric cranial sex assessment method using 3D technology that accommodates the medico-legal system, and their use of 3D models facilitates the technological transition to digitally archived skeletal collections. A total of 91 individuals of European biogeographical ancestry from the William M. Bass Donated Skeletal Collection (University of Tennessee Knoxville) were imaged using photogrammetry, turned into 3D models using Agisoft PhotoScan, and digitally evaluated using 3D Studio Max. This novel method digitally evaluated five cranial traits, including the nasal aperture height, nasal aperturewidth, mastoid length, the general size and architecture, and the supraorbital ridges, combining techniques that can only be done digitally with those that can be completed on the actual bone. Preliminary statistical tests demonstrate an overall accuracy rate of 90% when tested against the training sample (20 males, 20 females) and 75% when tested against the test sample (51 individuals). Although no intra- or inter-observer errorrate tests were done, and further testing on other skeletal collections is necessary, this method allows forensic anthropologists to perform relatively easy point-to-point measurements, the quantification of traditionally non-quantified traits, the possibility of reproducible results, and the ability for future analyses or research.

Congenital nasal pyriform aperture stenosis: Diagnosis, management and technical considerations

BackgroundCongenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal obstruction in neonates with respiratory distress manifestations. Diagnosis is made with craniofacial computed tomography, prompt and precise treatment creates good outcomes in these patients. AimTo present our experience in diagnosis and management considerations with this rare pathology and a case series of our surgically managed patients. MethodsA retrospective, analytical study of CNPAS patients surgically managed over a period of seven years. Evaluation and follow up was reviewed. ResultsThirteen patients were evaluated; pyriform aperture mean width was 5.5mm. Of these patients, 31% also had Congenital Midnasal Stenosis. Medical treatment failed for all the patients and they required surgical enlargement of the pyriform aperture. No complications were seen and all patients improved in symptoms and development. ConclusionsCongenital nasal obstruction can be fatal in new-borns, CNPAS is a rare differential diagnosis that must be completely evaluated, properly treated with conservative management and if it fails, with well-planned and executed surgery. Follow-up shows high rates of success.

Leprosy in skulls from the Paris Catacombs

Background: The Paris Catacombs contain the remains of approximately 6 million people dating back to the 15th century, when leprosy was endemic in France.Aims: The aim of this palaeopathological study was to identify the presence of leprosy in skulls from the Paris Catacombs.Subjects and methods: Macroscopic examination of skulls in situ for bone changes secondary to oronasal soft tissue infection by leprosy. Skulls were categorised as having “probable” signs of leprosy if they had an enlarged nasal (pyriform) aperture, resorption of the anterior nasal spine, and resorption of the alveolar processes of maxilla, and as having “possible” signs of leprosy if they met one of these three criteria.Results: Skulls from 123 sections within the Catacombs (approximately 1500 remains in total) were triaged, with 367 skulls identified as suitable for examination. Of these, 74 had central facial bone alterations/abnormalities and underwent detailed examination, yielding 0.5% (2/367) classified as having probable, and 5.7% (21/367) possible signs of leprosy.Conclusions: The proportion of skulls with probable signs of leprosy gives an approximate estimate (0.5%) for the prevalence of this disease in the population of Paris (or districts of Paris) during the 15–18th centuries.

Congenital nasal pyriform aperture stenosis with holoprosencephaly and Dandy–Walker malformation

Congenital nasal pyriform aperture stenosis (CNPAS) is a recognized but rare and unusual cause of nasal airway obstruction in neonates. We describe an infant who has CNPAS with megaincisor, holoprosencephaly, agenesis of the corpus callosum with Dandy–Walker malformation, and central diabetes insipidus to highlight the importance of recognizing the variable abnormalities associated with this condition.

Prolonged neonatal intubation: Prosthodontics beyond dentistry

Neonates with respiratory distress, inadequate gag reflex, poor sucking, and swallowing commonly require intubation as a routine treatment modality in the neonatal intensive care unit. It can be done by the nasal or oral route. Although nasotracheal intubation reduces the movement of the tube, it has some serious repercussions such as airway obstruction and possible hypoxia, leading to labored breathing, occlusion of the nasal aperture during a crucial period of development, nasal infections, and hypertrophy of the nasal lining. Hence, oral route is preferred over the nasal route as the oral mucosa is less susceptible to infection. However, an infant with an orotracheal tube is at risk for complications such as accidental extubation, damage to the maxillary alveolar ridge, development of a cleft palate, defective dentition, tracheal mucosal damage, subglottic stenosis, and laryngeal damage. Therefore, in an effort to reduce these complications, an appropriate recognition and dental intervention is required by the prosthodontist who by conferring with the prescribing physician could device a customized intraoral appliance for the neonate on prolonged intubation. Various intraoral appliances are being used to stabilize the tubes for infants who require prolonged intubation. For the present review, the database from various digital platforms was searched for studies published on prolonged neonatal intubation. The palatal appliances effectively stabilize the orotracheal and orogastric intubation tubes and prevent the associated complications. Thus, this early prosthodontic treatment for neonates requiring prolonged intubation further expands the scope of prosthetic dentistry to newer horizons in patient care and management.

Customised face mask: Solution to facial nerve blocks in COVID-19.

Sir, During coronavirus disease (COVID)-19 times, it is important to cover a patient's face with a protective mask. However, managing patients with chronic pain can become extremely challenging especially in cases of uncontrolled cranial neuralgias that may require nerve blocks on the face. Trigeminal nerve has been approached indirectly through injection in the pterygopalatine fossa in trauma patients.[1] Since the traditional mask covers most of the area of the face, it is not possible to perform these blocks with safety. Concurrently, the chances of acquiring COVID infection through aerosols become multifold if the patient's mask is removed during the procedure. We tried to tackle this encountered problem by customising the face masks for such procedures. This customised face mask has a smaller footprint covering only the nasal and oral apertures thus leaving ample space for head and neck nerve blocks to be performed. A smaller dimensioned cloth was cut and sewn. A single elastic band was attached from the edges of the mask, which wraps around the head area, combined with a flexible strip at the nasal end to ensure a proper fit and seal of the mask [Figures Figure 1a, b and 2a, b]. A similar mask is also being tried with success by dermatologists for laser hair removal of the facial region.[2] This mask has been used for performing infra-orbital, mental, mandibular, maxillary and glossopharyngeal nerve blocks in more than 10 patients, presenting to our OPD clinic. This mask provides great comfort and safety for both patients and doctors during this pandemic.Figure 1: (a) Inability to perform facial blocks with normal mask. (b) Customised face mask with wider work fieldFigure 2: (a) Front view of customised face mask with landmarks. (b) Side view of customised face mask.Financial support and sponsorship RM Aesthetics provided material and logistics support. Conflicts of interest There are no conflicts of interest. Acknowledgements We acknowledge Mrs. Manjeet Kaur for sewing and customising mask for us.

Thermoplastic nasal splint for post-burn nasal vestibular stenosis

Background. A simple design of a splint for nasal vestibular aperture maintenance and gradual dilation, made with low-cost and easily available material, is presented. Methods. A thermoplastic splint was used in a pilot case of nostril stenosis. The thermoplastic is heated up, then moulded to the desired shape, with the edges rolled up to prevent it from slipping into the nose. Results. The fact that the splint was rigid, yet mouldable, did not only maintain the post-surgical release of the nasal aperture, but also allowed further dilation as needed. Conclusion. Based on the initial experience, it seems that the splint is easy to clean at home, easy to reinsert and easy to remould when needed at the local clinic or at home, and did not dislodge spontaneously. Moreover, the material for its design was easily available and of low cost.

Radiologic, genetic, and endocrine findings in isolated congenital nasal pyriform aperture stenosis patients

BackgroundCongenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of upper airway obstruction in neonates. It can occur either associated with a solitary median maxillary central incisor (SMMCI) in 40–75% of cases or as an isolated morphogenic variant. Brain MRI is routinely performed in patients with CNPAS with a SCMMI due to the concomitant risks of intracranial midline defects of the hypothalamic-pituitary axis (HPA), holoprosencephaly, or associated endocrine dysfunction. However, the role of routine brain imaging and endocrinologic evaluation in patients with isolated CNPAS is not frequently studied given the assumption that isolated CNPAS is unlikely to be associated with any intracranial findings. ObjectivesTo evaluate intracranial findings on dual brain MRI imaging in isolated CNPAS patients and to determine if any radiologic, endocrinologic, or genetic abnormalities existed in these patients. MethodsWe performed a single-institution retrospective review and case series of patients with isolated CNPAS from 2006 to 2019. Findings from dual brain MRI imaging, cytogenetic and karyotype testing, and formal endocrinologic testing were analyzed for each patient and compared to reported findings in isolated CNPAS patients within the literature. ResultsFrom 2006 to 2019, 16/29 patients were identified at our institution with isolated CNPAS. Inpatient otolaryngologic consultation, CT, and brain MRI imaging was obtained after a mean postnatal age of 3.21 days, 13.5 days, and 35.91 days, respectively. Dual brain MRI imaging was obtained in 12/16 (75%) patients. In our patients, abnormal MRI findings included hypothalamic hamartoma, pars intermedius cyst, and grades 1 and 4 germinal matrix hemorrhages. No holoprosencephaly was found in any patient. Genetic testing was performed on 10/16 (62.5%) patients. Karyotyping was normal in all patients and microarray testing was abnormal in 2/10 patients that represented a 2p16.3 deletion in one patient and a 7q36 deletion causing an unbalanced translocation mutation of the Sonic Hedgehog gene in the second patient. In the latter patient, a hypothalamic hamartoma and panhypopituitarism was found. Endocrine evaluation was performed in 5 patients and was normal in 3/5 patients. ConclusionsOur case series of isolated CNPAS patients identified multiple abnormalities on radiologic, genetic, and endocrine testing; one of which that involved a defect of the HPA with panhypopituitarism resulting from a hypothalamic hamartoma. Based upon our findings, dedicated brain MRI imaging, endocrinologic, and genetic testing, should likely be considered for any newly diagnosed, isolated CNPAS patient given the uncommon but potential risk for associated intracranial abnormalities.

Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia.

Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited. Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/μL. We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/μL) with the following ranges: 14.7% with 50 to <100 K/μL, 20.6% with 20 to <50 K/μL, 10.6% with 10 to <20 K/μL, 4.1% with <10 K/μL. Platelet transfusion was given in 90.6% of those with platelets <10 K/μL and 55.5% of those with platelets 10 to <20 K/μL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/μL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.

Congenital nasal pyriform aperture stenosis: Diagnosis, management and technical considerations

BackgroundCongenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal obstruction in neonates with respiratory distress manifestations. Diagnosis is made with craniofacial computed tomography, prompt and precise treatment creates good outcomes in these patients. AimTo present our experience in diagnosis and management considerations with this rare pathology and a case series of our surgically managed patients. MethodsA retrospective, analytical study of CNPAS patients surgically managed over a period of seven years. Evaluation and follow up was reviewed. ResultsThirteen patients were evaluated; pyriform aperture mean width was 5.5mm. Of these patients, 31% also had Congenital Midnasal Stenosis. Medical treatment failed for all the patients and they required surgical enlargement of the pyriform aperture. No complications were seen and all patients improved in symptoms and development. ConclusionsCongenital nasal obstruction can be fatal in new-borns, CNPAS is a rare differential diagnosis that must be completely evaluated, properly treated with conservative management and if it fails, with well-planned and executed surgery. Follow-up shows high rates of success.

Congenital nasal pyriform aperture stenosis: Analysis of twenty cases at a single institution

ObjectivesCongenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of neonatal respiratory distress that is difficult to treat. The primary objective of this study was to identify factors that predict the need for initial and revision surgery for CNAPS. The secondary objective is to identify risk factors in maternal history associated with the development of CNPAS. MethodsInfants with CNPAS between 2010 and 2017 were identified by ICD- 9 and 10 codes. Demographics, maternal history, anatomic features on imaging and medical and/or surgical management were reviewed. Frequencies, means and standard deviations were calculated. A p-value <.05 was considered significant. ResultsTwenty infants were included. All underwent flexible nasal endoscopy with inability to pass the scope in either nostril in 65% of infants. Nineteen had a CT scan and 13 had a MRI with midline defects in 76.3% and 53.8%, respectively. Solitary central mega-incisor was present in 65%. Half underwent surgical intervention at a mean age of 74.8 days, with 90% requiring revision surgery. There was no difference in pyriform aperture distance in the surgical and non-surgical patient subgroups (5.4 mm and 5.2 mm, p = .6 respectively). No specific variables were predictive of need for initial or revision surgery. Maternal diabetes mellitus (MDM) was found in 55% of mothers of infants with CNPAS. ConclusionPyriform aperture distance was not a predictor of surgical intervention. MRI should be considered in all infants with CNPAS as the rate of intracranial complications is high. MDM may be a risk factor for CNPAS.

Archaic human remains from Hualongdong, China, and Middle Pleistocene human continuity and variation

Middle to Late Pleistocene human evolution in East Asia has remained controversial regarding the extent of morphological continuity through archaic humans and to modern humans. Newly found ∼300,000-y-old human remains from Hualongdong (HLD), China, including a largely complete skull (HLD 6), share East Asian Middle Pleistocene (MPl) human traits of a low vault with a frontal keel (but no parietal sagittal keel or angular torus), a low and wide nasal aperture, a pronounced supraorbital torus (especially medially), a nonlevel nasal floor, and small or absent third molars. It lacks a malar incisure but has a large superior medial pterygoid tubercle. HLD 6 also exhibits a relatively flat superior face, a more vertical mandibular symphysis, a pronounced mental trigone, and simple occlusal morphology, foreshadowing modern human morphology. The HLD human fossils thus variably resemble other later MPl East Asian remains, but add to the overall variation in the sample. Their configurations, with those of other Middle and early Late Pleistocene East Asian remains, support archaic human regional continuity and provide a background to the subsequent archaic-to-modern human transition in the region.

The earliest recorded case of lepromatous leprosy in continental Croatia

Among 89 skulls from the Bijelo Brdo site in mainland Croatia dated between the 10th and 11th centuries, two show osteological features characteristic for lepromatous leprosy. Both skulls have female traits. An adult individual exhibits inflammatory changes on the palatine process, the alveolar process of the maxilla, the inferior nasal aperture, and on the anterior nasal spine. A younger individual, between 15 and 17 years at the time of death, exhibits less pronounced changes on the inferior nasal aperture, and the anterior nasal spine. Differential diagnosis excluded fungal infections (aspergillosis, mucormycosis), bacterial infections (actinomycosis, tuberculosis), and granulomatous disorders (sarcoidosis, and treponemal diseases). Molecular genetic analysis targeting the repetitive elements RLEP (37 copies/cell) and RepLep (15 copies/cell) of the M. leprae genome confirmed the presence of the disease in the adult individual. The possible geography of the spread of this infectious disease in Croatia is discussed.

The Infraorbital Foramen Location in the Perinatal Maxilla: Implications for Infraorbital Nerve Block

Bilateral infraorbital nerve block is performed in infants for the management of pain after cleft‐lip repair. The procedure involves the injection of anesthetic near the emergence of the infraorbital nerves in the face at the infraorbital foramen. In adults, infraorbital foramen location is oftentimes estimated via measurements from the lateral nasal aperture and the infraorbital margin; however, these measurements have not been described in the perinatal population. Therefore, this study assesses the distances from the lateral nasal aperture and the infraorbital margin to the infraorbital foramen in 66 fetal and infantile maxillae ranging from 5 months intrauterine development to 15 months postnatal development. The best‐fit linear model for IOF location is with regard to the distance from the lateral nasal aperture to the IOF. The model is given by the formula Distance = 0.1747 × Age (in developmental months) + 4.4433 and has an r2 value of 0.6145. Linear modeling with respect to the distance from the infraorbital margin to the IOF however was poor with regard to goodness‐of‐fit (r2 = 0.1636). The distance from the infraorbital foramen at 5 months intrauterine age was 2.9mm while, at one year post‐natal was 3.4mm (difference = 0.5mm) and therefore represents little change in maxillary growth in that dimension. On the other hand distance from the lateral aperture at 5 months development was 5.3 mm and at one year was 7.6mm (difference = 2.3mm). The results of this study suggest that the IOF location can be approximated, particularly with regard to the distance from the lateral aperture as a function of age. The results of the study will help to optimize infraorbital nerve block in young patients recovering from cleft‐lip surgery.Support or Funding InformationWV Research Challenge Fund [HEPC.dsr.17.06]This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Accidental Swallowing of Dental Implant: Complication of Transnasal Endoscopic Removal From Maxillary Sinus.

Transnasal endoscopic removal of displaced dental implants in the maxillary sinus can be done easily under local anesthesia. However, very little is known regarding the precaution of this technique. In this report, we present the case of a 63-year-old man who visited the otolaryngologic department with a displaced dental implant in the maxillary sinus. Transnasal endoscopic removal of the displaced dental implant was planned and performed. However, the displaced dental implant was lost during removal. The implant was not seen in the other parts of the nasal cavity nor in the other parts of the oral cavity. Finally, radiographs revealed the presence of the dental implant at the level of the esophagus, although the patient did not notice anything because of local anesthesia. Thus, we conclude that operators should take into account the possibility of aspiration or swallowing of an implant through the posterior nasal aperture during the removal procedure. Precautions should be taken to avoid the possibility of implant aspiration or implant ingestion.

Evaluation of sites of velopharyngeal structure augmentation in dogs for improvement of velopharyngeal insufficiency

BackgroundVelopharyngeal structure augmentation methods are used as alternatives to velopharyngeal plasty. Anatomic sites of implantation/injection vary widely due to a lack of standardized criteria. Here, we experimentally investigated optimal sites of velopharyngeal structure augmentation via saline injection in dogs as they naturally exhibit velopharyngeal insufficiency (VPI).MethodsVelopharyngeal structure augmentation was performed on 10 beagles (age range: 20–24 months; weight range: 9–12 kg). Saline containing 1/80,000 epinephrine was injected intraorally in 1-mL increments into the nasal mucosa of the soft palate (n = 4), posterior pharyngeal wall (n = 3), or bilateral pharyngeal walls (n = 3) of each dog. Nasal air leakage was measured under rebreathing until velopharyngeal closure was achieved; the measurement was performed using flow meter sensors on both nasal apertures, and the oral cavity was filled with alginate impression material to prevent oral air leakage.ResultsPre-injection, the dogs exhibited an average of 0.455 L/s air leakage from the nasal cavity. The dogs with saline injected into the nasal mucosa of the soft palate achieved steady augmentation, and nasal air leakage disappeared under rebreathing following 6-mL saline injection. Conversely, nasal air leakage remained in the dogs with saline injected in the posterior pharyngeal wall or bilateral pharyngeal walls.ConclusionsDuring VPI treatment in dogs, augmentation was most effective at the nasal mucosa of the soft palate. Improvement in nasal air leakage was highly dependent on the saline injection volume. Although velopharyngeal structures vary between dogs and humans, velopharyngeal closure style is similar. Thus, our results may aid in the treatment of VPI patients.

An Unusual Cause of Upper Airway Obstruction in Newborn: Congenital Nasal Pyriform Aperture Stenosis

An Unusual Cause of Upper Airway Obstruction in Newborn: Congenital Nasal Pyriform Aperture Stenosis