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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4450_Библиотеки_им_академика_М_И_Перельмана
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2.1.5Ski-Slope Nose
The so-called ski-slope nose is a common “postsurgical
look” and one of the most well-known complications of
rhinoplasty. The nasal dorsum is more or less sloping due to
excessive lowering of the bony and cartilaginous dorsum,
especially in the region of the K area (▶ Fig. 2.18; see also ▶
Fig. 6.71, ▶ Fig. 6.72, ▶ Fig. 6.73, and ▶ Fig. 6.74). The surgeon
did not take into account that the dorsal skin over this
region is thinner than over the cartilaginous dorsum (see ▶
Fig. 1.31). Sagging of the cartilaginous dorsum due to
inadequate fixation of the cartilaginous septum may also
play a role. A ski-slope deformity can be prevented by: (1)
limiting the amount of reduction of the lower part of the
bony dorsum; (2) fixing the cartilaginous septum to the
premaxilla (or the anterior nasal spine) and the columella
to prevent sagging of cartilaginous dorsum; and (3)
transplanting some crushed septal cartilage under the skin
in the K area.
Fig. 2.18Ski-slope syndrome. Both the bony and cartilaginous pyramids are concave.
This syndrome is seen after excessive reduction of a bony and cartilaginous hump. The
dorsum is usually more or less irregular on palpation and may have an “open roof” (see
▶ Fig. 2.19 and ▶ Fig. 2.20).
2.1.6Open Roof Syndrome
Open roof syndrome is characterized by neuralgic
symptoms that are caused by a traumatic defect in the bony
(and cartilaginous) dorsum. The most common cause is
resection of a bony and/or cartilaginous hump with
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subsequent closure of the dorsum. Cottle was the first to
describe this syndrome as an entity.
Its main symptoms are tenderness of the bony dorsum, pain
when wearing eyeglasses, and pain on inspiring cold air. On
examination, an irregular defect in the bony dorsum and K
area can be seen and palpated through thin and adherent
skin with telangiectasias (▶ Fig. 2.19 and ▶ Fig. 2.20).
Fig. 2.19Open roof syndrome. Defect of dorsum (open roof) visible and palpable
through the skin.
Fig. 2.20Open roof syndrome. Defect of bony and cartilaginous dorsum due to
resection of a bony and cartilaginous hump.
The symptoms are caused by a defect in the bony roof and
damage to the external nasal branches of the anterior
ethmoidal nerve (see ▶ Fig. 1.56). As a result of the defect,
the outside skin and the inside nasal mucosa are in direct
contact, which may induce neuralgia. Evidence supporting
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this pathogenetic explanation is the fact that symptoms
disappear after secondary closure of the dorsum through
osteotomies and interposition of a layer of connective
tissue or soft cartilage between the skin and the bony
defect.
2.1.7Lobular Inspiratory Insufficiency
Syndrome (“Alar Collapse”)
Lobular inspiratory insufficiency syndrome is characterized
by collapse of the lateral wall of the lobule during the
inspiratory phase of breathing. As a result of negative
pressure on inspiration, the lateral nasal wall is sucked
inward and collapses. This condition was already
recognized as a pathological entity in the second half of the
19th century and was called “alar collapse” (▶ Fig. 2.21).
Alar collapse is a misleading term, however, and has
induced many surgical mistakes. The collapse of the mobile
lateral nasal wall is, in many cases, not due to alar
weakness. The most common causes are as follows:
Slitlike nostrils, as in the prominent-narrow pyramid
syndrome (see ▶ Fig. 2.12)
Narrowing of the nostrils and/or vestibules due to an
abnormally broad columella (see ▶ Fig. 2.87), protrusion
of the medial crura (see ▶ Fig. 2.88), a protruding,
dislocated caudal end of the septum (see ▶ Fig. 2.100),
or alar pathology (see ▶ Fig. 2.78, ▶ Fig. 2.79, ▶ Fig. 2.80, ▶
Fig. 2.81, ▶ Fig. 2.82, ▶ Fig. 2.83, and ▶ Fig. 2.84)
Narrowing of the valve area due to pathology of the
septum, triangular cartilage, or inferior turbinate (see
▶ Fig. 2.102 and ▶ Fig. 2.104)
All these kinds of pathology, sometimes in combination,
may lead to collapse of (parts of) the lateral wall of the
lobule. For this reason, we prefer to speak of the “lobular
inspiratory insufficiency syndrome.” ▶ Table 2.1 gives an
overview of the most frequent causes.
Table 2.1Main causes of lobular inspiratory insufficiency
Nostril Slitlike nostrils (prominent-narrow pyramid
syndrome)
Nostril vestibule Broad columella
Protruding medial crura
Dislocated and protruding caudal septal
end
Vestibule Protruding lateral crus
Valve area Stenosis due to:
septal pathology
synechiae
triangular cartilage pathology
hyperplasia of inferior turbinate
head
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Fig. 2.21Lobular inspiratory insufficiency syndrome. The lateral wall of the lobule(s)
collapses on inspiration. This syndrome may be caused by slitlike nostrils, narrowing of
the naris and/or vestibule, the caudal part of the septum, or pathology of the valve area.
2.1.8Middle Meatus Obstructive
Syndrome
Middle meatus obstructive syndrome is characterized by a
set of symptoms that may occur when the middle meatal
passage is obstructed. The main symptoms of this
syndrome are:
Headaches, varying from vague pressure feelings to
pain, usually localized at the level of the bony pyramid
and radiating in a frontal and orbital direction (anterior
or posterior ethmoidal neuralgic syndrome)
Sinusitis as a result of obstruction of the ostia of the
maxillary and frontal sinus and anterior ethmoidal cells
Impaired breathing
Hyposmia
Obstruction of middle meatal areas has diverse causes,
both anatomical and pathological. Analysis of the factors
contributing to the syndrome is of utmost importance in
selecting the mode of treatment. The following anatomical
features may be involved: the septum, middle turbinate,
uncinate process, ethmoidal bulla, infundibulum
ethmoidale, and the mucosa overlying these structures. ▶
Table 2.2 gives an overview of the most common causes.
Table 2.2Main conditions that may contribute to middle meatus obstructive syndrome
Septum Deviation or thickening opposite the
middle turbinate
Middle turbinate Concha bullosa or spongiosa
lateral curling
Uncinate process Long and/or medially curled
Ethmoidal bulla Large
Ventral location
Infundibulum Narrow
Mucosa Swelling
Polypoid degeneration
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Septum: A deviation or a thickening of the septum in area 4
at the level of the head of the middle turbinate can easily
lead to temporary or permanent contact between the septal
and turbinate mucosa. Septal surgery may be helpful in
these cases (▶ Fig. 2.22).
Fig. 2.22Middle meatus obstructive syndrome. Obstruction of the middle meatus by a
septal deviation.
Middle turbinate: A concha bullosa is a normal anatomical
variation found in about 25% of the population. The
turbinate skeleton may be very thick and spongiotic. In
combination with other conditions, these variations can
play a major role in the development of an obstructive
syndrome (▶ Fig. 2.23). Middle turbinate surgery might then
be indicated.
Fig. 2.23Middle meatus obstructive syndrome. Obstruction of the middle meatus by a
bullous middle turbinate.
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