Nasoethmoid Region Research Articles

Reliability and accuracy of a semi-automatic segmentation protocol of the nasal cavity using cone beam computed tomography in patients with sleep apnea.

The objectives of this study included using the cone beam computed tomography (CBCT) technology to assess: (1) intra- and inter-observer reliability of the volume measurement of the nasal cavity; (2) the accuracy of the segmentation protocol for evaluation of the nasal cavity. This study used test-retest reliability and accuracy methods within two different population sample groups, from Eastern Asia and North America. Thirty obstructive sleep apnea (OSA) patients were randomly selected from administrative and research oral health data archived at two dental faculties in China and Canada. To assess the reliability of the protocol, two observers performed nasal cavity volume measurement twice with a 10-day interval, using Amira software (v4.1, Visage Imaging Inc., Carlsbad, CA). The accuracy study used a computerized tomography (CT) scan of an OSA patient, who was not included in the study sample, to fabricate an anthropomorphic phantom of the nasal cavity volume with known dimensions (18.9ml, gold standard). This phantom was scanned using one NewTom 5G (QR systems, Verona, Italy) CBCT scanner. The nasal cavity was segmented based on CBCT images and converted into standard tessellation language (STL) models. The volume of the nasal cavity was measured on the acquired STL models (18.99 ± 0.066ml). The intra-observer and inter-observer intraclass correlation coefficients for the volume measurement of the nasal cavity were 0.980-0.997 and 0.948-0.992 consecutively. The nasal cavity volume measurement was overestimated by 1.1%-3.1%, compared to the gold standard. The semi-automatic segmentation protocol of the nasal cavity in patients with sleep apnea and by using cone beam computed tomography is reliable and accurate. This study provides a reliable and accurate protocol for segmentation of nasal cavity, which will facilitate the clinician to analyze the images within nasoethmoidal region.

The Specific Magnetic Resonance Imaging Indicators in Predicting Clear-Cell Renal Cell Carcinoma Metastatic to the Sinonasal Region.

The aim of this study was to determine the valuable magnetic resonance imaging (MRI) features of sinonasal metastatic clear-cell renal cell carcinoma (cc-RCC), especially focusing on its dynamic-enhanced characteristics. The conventional and dynamic-enhanced MRI findings of 8 patients with histopathologically confirmed sinonasal metastatic cc-RCC were reviewed by 2 radiologists. The control group of 8 patients with capillary hemangioma underwent the same MRI protocol. Metastatic cc-RCCs arose from the nasoethmoid region, maxillary sinus, posterior ethmoid and sphenoid sinus, and nasal cavity in 2 patients in each. These lesions were well circumscribed and the mean maximum dimension was 42 mm. The signal intensity of these lesions was isointense to brain stem on both MR T1- and T2-weighted images. All metastatic tumors showed vivid enhancement on enhanced T1-weighted image. Multiple flow voids within these metastatic lesions were identified in 6 patients. Peripheral cyst was detected around the metastatic tumor in 4 patients. Metastatic cc-RCCs exhibited a characteristic type 4 time intensity curve (TIC) similar to that of the internal carotid artery, whereas capillary hemangiomas showed a type 3 TIC on dynamic-enhanced MRI. A hypervascular mass with the characteristic type 4 TIC in the sinonasal region is highly suggestive of a metastatic cc-RCC.

Extraoral anatomy in CBCT – a literature review. Part 1: Nasoethmoidal region

Cone beam computed tomography has become a widely used imaging technique for dental indications. Depending on the selected size of the field of view, anatomical structures outside the dentomaxillary complex become visible. As a consequence, the clinician must be able to interpret also those anatomical regions. In this article, the anatomy of the nasoethmoidal region is presented based on a literature review. The nose is characterized by the nasal septum and the superior, middle, and inferior conchae. The turbinates may be pneumatized (concha bullosa), mainly the middle concha. The ethmoid bone has a complex morphology (ethmoid labyrinths) and contributes with its perpendicular plate to the nasal septum. Other structures of the septum include the vomer and the septal cartilage. The nasal meatuses stabilize the airflow and direct the inhaled air to the nasopharynx via the choanae. The middle nasal meatus, which is also a part of the so called ostiomeatal complex, serves as the major drainage area (semilunar hiatus) of the paranasal sinuses, i.e., maxillary sinus, anterior ethmoid cells, and frontal sinus. Posterior ethmoid cells empty into the superior meatus and the sphenoid sinus drains into the sphenoethmoidal recess, located above the superior concha. The nasolacrimal duct that is running along the middle portion of the lateral nasal wall opens into the inferior nasal meatus.

Extraoral anatomy in CBCT – a literature review. Part 1: Nasoethmoidal region

In this article, the anatomy of the nasoethmoidal region is presented based on a literature review.

Imaging characteristics and clinical outcomes of biphenotypic sinonasal sarcoma.

ObjectivesBiphenotypic sinonasal sarcoma (BSS) is a new, rare tumor characterized by concomitant neural and myogenic differentiation. The aim of this study is to describe the imaging characteristics and clinical outcomes of this neoplasm.MethodsA retrospective review of BSS patients surgically treated within a tertiary academic health care system was performed. Imaging characteristics and clinical outcomes were reviewed.ResultsFive patients underwent surgical resection of BSS tumors. Negative surgical margins were achieved in four (80%) patients. There were no deaths but two (40%) patients developed local recurrences during the postoperative follow‐up period (median follow‐up 31.4 months). Review of imaging characteristics revealed a median tumor size of 3.8 cm in greatest dimension. All tumors were unilateral and centered within the nasoethmoidal region. In all cases, the tumors extended to the nasal septum, lamina papyracea, and anterior skull base with variable degrees of erosion through these structures. On CT, involved bony structures demonstrated mixed lytic and sclerotic pattern, with definitive hyperostotic bone identified in four (80%) cases. On MRI, tumors were isointense‐to‐mixed iso/hypointense on both T1‐ and T2‐weighted sequences with one tumor demonstrating mixed T2 hyperintensity. All cases demonstrated gadolinium contrast enhancement.ConclusionsBSS is a locally aggressive tumor with a low risk of regional or distant metastases but has a significant rate of recurrence even with adequate resection. Despite its rarity, BSS should be considered in the differential diagnosis when imaging demonstrates a unilateral nasoethmoidal mass that is predominantly isointense to cerebral gray matter on T2‐weighted MRI and is hyperostotic on CT.Level of Evidence4

Sinonasal Alveolar Rhabdomyosarcoma in an Adult Patient: A Case Report and Review of the Literature

We report on a patient who presented to the ENT service with right side nasal obstruction. Imaging studies revealed an aggressive non-calcified solid heterogeneous mass centered in the right naso ethmoidal region. The mass was hyper enhanced following contrast media administration. The patient underwent partial tumor resection and a biopsy was performed confirming the presence of Solid Alveolar Rhabdomyosarcoma. The patient was treated with chemo-radiation therapy.

Imaging Appearance of SMARCB1 (INI1)-Deficient Sinonasal Carcinoma: A Newly Described Sinonasal Malignancy.

SMARCB1 (INI1)-deficient sinonasal carcinomas were first described in 2014, and this series of 17 cases represents the first imaging description. This tumor is part of a larger group of SMARCB1-deficient neoplasms, characterized by aggressive behavior and a rhabdoid cytopathologic appearance, that affect multiple anatomic sites. Clinical and imaging features overlap considerably with other aggressive sinonasal malignancies such as sinonasal undifferentiated carcinoma, which represents a common initial pathologic diagnosis in this entity. SMARCB1 (INI1)-deficient sinonasal tumors occurred most frequently in the nasoethmoidal region with invasion of the adjacent orbit and anterior cranial fossa. Avid contrast enhancement, intermediate to low T2 signal, and FDG avidity were frequent imaging features. Approximately half of the lesions demonstrated calcification, some with an unusual "hair on end" appearance, suggesting aggressive periosteal reaction.

Neurological Involvement in Erdheim-Chester Disease.

Dear Editor, We present a clinical case of a 74-year-old man with a personal record of nasal polyps and sinusitis. The patient was first admitted to our Department of Neurology with symptoms of instability and dizziness of 6 months of evolution, which subsided spontaneously. Physical examination revealed amaurosis with an afferent pupillary defect in the left eye associated with conjunctival injection, with a slightly hyperemic optic nerve head and mild proptosis in that same eye, as well as paresthesia of the first branch of the trigeminal nerve on the left side of his face. The patient was hospitalized, and several analysis and diagnostic test was performed, together with a study of autoimmunity and tumor markers, CSF analysis, and brain MRI. The analysis revealed the following abnormal findings: erythrocyte sedimentation rate, 67 mm; antinuclear antibody inconclusive (1/80); positive for anti-DNA (37 UI/mL), perinuclear antineutrophil cytoplasmic antibody and antimyeloperoxidase-IgG (45 U/mL); and negative for antiproteinase 3 IgG. All other studies yielded normal findings. Brain MRI revealed a lesion with signs of aggressiveness in the bilateral nasoethmoid region, with an epidural component in that area, and meningeal thickening and hyperenhancement (Fig. 1). Immunohistochemical studies of a biopsy sample taken from the lesion revealed histiocytosis with foamy histiocytes (positive for CD68, and negative for S100 and CD1a), as well as intense lymphoid infiltration and eosinophils (Supplementary Figs. 1 and 2 in the online-only Data Supplement). These data confirmed the diagnosis of Erdheim-Chester disease (ECD). Fig. 1 Brain MRI. A: An axial, T1-weighted cranial MRI image obtained after administering intravenous contrast medium, the arrow point the epidural enhancement on the frontal lobe. B: A coronal, T1-weighted cranial MRI image showing an infiltrating-like lesion ... Tc-99 scintigraphy was performed, but no lesions compatible with ECD were observed. A body CT scan revealed emphysematous air spaces with paraseptal and centrilobular distributions in both upper lobes. These data, together with the results of aspirometry study, confirmed an interstitial pattern. Prednisolone was added to the treatment, which resulted in a progressive improvement of the neurological symptoms. The patient was discharged after 10 days of treatment. The patient experienced no recurrence of the symptoms during a follow-up period of 4 years. EDC is a rare form of non-Langerhans cell histiocytosis, for which there are approximately 400 cases described in the medical literature.1 It is a systemic disease that affects mainly adults between their fifth and seventh decades of life; the prevalence is slightly higher in men.2 ECD is diagnosed through the assessment of clinical symptoms and radiological and histological criteria. The main diagnostic criteria are histological, and are usally sufficient to confirm the disease.2 The histology of ECD is characterized by histiocytic infiltration with special histiocyte that do not contain Birbeck granules, and an immunohistochemical profile that is characterized by positivity to CD68 and negativity to CD1a and S100.3 The cardinal sign of ECD is bone involvement, which is observed in 96% of patients.1 CNS involvement occurs in 51% of the patients with ECD, and is responsible for 29% of all deaths due to the disease.1 The neurological clinical symptoms, in lowering order of frequency, are diabetes insipidus, exophthalmos, cerebellar ataxia, panhypopituitarism, and papilledema.2 Brain MRI describes two patterns: infiltrating and nodular thickening of the dura mater; the former is the most frequently observed.4 The low prevalence of this disease means that no standardized treatment has yet been established.4 However, there are now some first-line drugs, such as interferon-α, which exert positive effect on survival.1 However, the beneficial effects of interferon-α have yet to be clarified.4 Corticoids are used to control the symptoms of ECD.2 Vemurafenib (a BRAF inhibitor) induces a fast clinical improvement in patients who are positive for the BRAF V600E mutation, which is found in 54% of ECD patients.3 The average 1- and 5-year survival rates of the disease are 95% and 68%, respectively.2 Involvement of the CNS has recently been proposed as the only independent clinical prognostic factor for a poor survival.1 The patient described herein presented with neurological symptoms and lung involvement. Only an anatomopathological analysis of biopsy samples allowed a definitive diagnosis, since the patient did not present any other symptoms.

Craniofacial anomalies with toothy nose

A simple subcutaneous lesion such as an epidermoid cyst can present as an aesthetic challenge when located in the nasal tip. Usually the nasal dermoid presents as swelling over the dorsum of nose extending from the nasal tip to the nasal bridge with or without intracranial extensions. In some cases, the overlying skin gets rupture and underlying abnormal structures developed from pluripotent cells of dermoid become visible with variable discharges such as cerebrospinal fluid or sequestrum. Origin of nasal dermoid sinus cyst (NDSC) during embryological development requires two necessary and sufficient conditions. One is competence of the ectodermal and meso-ectodermal cells to form dermoid tissue with epithelial-mesenchymal interactions and second, presence of a topographical site of ectodermal inclusion, which fits well with the various clinical presentations of NDSCs. The case presented here has naso-ethmoidal dermoid cyst with ectopic teeth at the tip of the nose. The patient had a cranial defect with bulging of tissue in naso-ethmoidal region that was in line of 1-13 facial cleft of Tessier. Computerized tomography revealed a bony gap in the region of right fronto-ethmoidal region and brain cyst with craniosynostosis in left frontoparietal suture. Transcranial approach was used to manage the case and all the teeth at the tip of the nose were removed.

Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions.

Orbital skeletal injuries are frequently associated with other significant injuries and require a substantial surgical effort to correct. The use of a unified classification of orbital injury may better predict the surgical effort required to correct such injuries and help with future comparisons of results. In an attempt to summarize the principles of reconstruction of the orbital skeleton following trauma and introduce a unified classification system for orbital injuries, a retrospective review of all consecutive orbital reconstructions in a tertiary care teaching hospital was conducted. The nasoethmoidal region was involved in 32%, the zygomatic complex in 50%, and the frontal region in 28% of orbital fractures. Of the orbital walls, four walls were involved in 5%, three walls in 17%, two walls in 30%, and one wall in 53%. Associated ocular and neurologic injury was encountered in 33% and 57% of patients, respectively. Regions of fixation ranged from one to eight. Bone grafts were used in 20% and titanium mesh in 34% of the orbits. In general, the authors recommend an aggressive approach to orbital injuries, addressing all associated injuries simultaneously.

Brachytherapy for recurrent nasopharyngeal and nasoethmoidal tumours

Recurrent or persistent carcinoma of the nasopharynx or naso-ethmoid region occurs even after combined surgery and radical external irradiation. The confined bony access and proximity of vital structures may compromise resection margins. Brachytherapy using implantable radioactive gold or iodine seeds is a useful adjunct to the skull base surgeon in eliminating residual microscopic disease. We report nine cases with recurrent or persistent disease of the nasopharynx or naso-ethmoid regions treated with brachytherapy with encouraging results.

Inferior hemi-maxillectomy for treatment of palatal tumors.

The traditional surgical approach to a malignancy of the maxilla has been the Weber-Ferguson incision, giving an open access to the maxilla that is normally removed enbloc including the orbital floor.’ If the orbital floor is involved by the tumor, the orbital contents are included in the resection and, if necessary, the naso-ethmoidal region can also be included. Resections may also involve the base of the skull. Bone cuts for maxillectomy were originally made with chisels or drills, and a Gigli saw was used for the palatal cuts. With modern imaging techniques. including computed tomographic (CT) scanning and magnetic resonance imaging, it is possible to localize tumors with much greater accuracy so that, in some cases, good surgical clearance is possible without resecting the whole maxilla (Fig. 1). This is also aided by the instruments and techniques that have been learned through orthognathic surgery. A technique is described that has been found successful for the treatment of small malignancies of the palate and floor of the sinus using orthognathic saws and drills to carry out a limited hemi-maxillectomy.

Clips for the control of hemorrhage from the bitemporal scalp flap

The bitemporal flap has many applications, allowing good access to the frontal bone, temporal fossae, zygomatic bones and arches, orbital rims, nasoethmoidal region and posterior walls of the maxilla. As a result of its versatility and the wellhidden scar it produces, the flap is now widely used in maxillofacial surgery. Access to the nasoethmoidal region can be achieved by an incision across the nasal bridge, which can be extended into the eyebrows on either side. The scalp has a rich blood supply which is derived from the external carotid artery via the occipital, posterior auricular and superficial temporal arteries, and from the internal carotid artery via the supraorbital and supratrochlear arteries. These ar-

Craniofacial resection for ethmoid carcinoma in children

The combined craniofacial resection is a well-established method of managing invasive primary malignant nasoethmoidal disease in adults, and serves as an excellent surgical technique for the en bloc eradication of these lesions [6]. The nasoethmoid region is a relatively uncommon site for the development of primary carcinoma. Less than 3% of cancers involving the adult upper aerodigestive system arise in this area [11,13]. Because similar lesions occur in the pediatric population even less frequently, there has been little opportunity to gain the knowledge necessary to develop a standardized treatment of this disease in children. We report the use of a combined therapeutic regimen consisting of cobalt-60 radiotherapy, surgery and chemotherapy, to manage a primary malignant undifferentiated carcinoma of the ethmoid complex in an adolescent. Since the initiation of treatment at the Cincinnati Children's Hospital, the child has remained free of tumor for 24 months. The techniques of craniofacial resection for the removal of certain tumors in the nasoethmoid complex of adults may be easily adapted for use in the pediatric population, and should be included in the surgical armamentarium of the otolaryngologist providing this type of health care for children.

The pattern of lacrimal injuries in naso-ethmoid fractures

Summary The relatively infrequent occurrence of epiphora following fractures of the naso-ethmoid region is noted. This is thought to be due to the protective influence of the medial canthal ligament which prevents tearing of the upper lacrimal pathways. Except for incised or external penetrating wounds, most injuries to the lacrimal pathways occur at or near the junction of the orbital and nasal sections. Failure to recognise this, associated with blind compression of inaccurately reduced bone fragments, may lead to obstruction at this level. Correct treatment, especially in severe naso-ethmoid injuries, involves exploration and anatomical reconstruction of the medial and inferior orbital margins.

Medial canthoplasty.

THE PURPOSE of this communication is to introduce a modification of the medial canthoplasty procedure previously described by Converse and Smith.^1-5These authors proposed a wire transfixion technique in unilateral and bilateral canthoplasties for naso-orbital fractures. This procedure was also used in conjunction with dacryocystorhinostomies, whenever indicated. In addition, it was successfully employed in the correction of congenital telecanthus. At this point it may be well to define this term as used by J. O. Mustardé: Telecanthus, which is defined as increased breadth between the medial canthi, must be carefully distinguished from hypertelorism, which is increased breadth between the eyes, as measured by increased interpupillary distance. In the latter condition, the most significant clinical symptom is the increased separation of the eyes, and the most important radiological observation is the excessive breadth of the naso-ethmoid region and intraorbital width. In telecanthus, on the other hand, the medial canthi may