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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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Uncinate process: The uncinate process may follow a
medial instead of a lateral course. Its end may also be
curved medially downward, suggesting the presence of a
second, more laterally localized, medial turbinate. These
variations can easily contribute to obstruction of the middle
meatus.
Ethmoidal bulla: The size and location of the ethmoidal
bulla shows considerable interindividual variation. When
large and relatively more ventral than average, it may be in
more or less permanent contact with the middle turbinate
or the lateral wall of the infundibulum. In this case, it will
obstruct the entrance to the infundibulum.
Infundibulum ethmoidale: The depth and width of the
infundibulum may be another cause of middle meatus
obstruction syndrome.
Nasal mucosa: Allergy, hyperreactivity, and infection will
induce mucosal swelling. This may lead to contact between
the septum and the middle turbinate as well as to
obstruction of the infundibulum and ostiomeatal complex.
In chronic conditions, hyperplasia and polypous
degeneration may result.
In mild cases, conservative treatment (antibiotics,
corticosteroid sprays) is prescribed. Polyps resistant to
conservative treatment have to be resected, and
infundibulotomy and/or anterior ethmoidectomy may be
indicated. A septal deformity and concha bullosa may be
addressed during the same surgical procedure.
2.1.9Wide Nasal Cavity Syndrome
(“Empty Nose” Syndrome)
Wide nasal cavity syndrome or “empty nose syndrome,” as
Stenquist and Kern 1996 have named it, is characterized by
an abnormally wide nasal cavity with crusting and a variety
of complaints. It is usually secondary to extensive surgery
of the inferior and/or middle turbinate (▶ Fig. 2.24 and ▶ Fig.
2.25).
Fig. 2.24Wide nasal cavity syndrome, or empty nose syndrome. Coronal CT scans
before bilateral infundibulotomy and resection of the inferior turbinates.
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Fig. 2.25Wide nasal cavity syndrome, or empty nose syndrome. Coronal CT scans after
bilateral infundibulotomy and resection of the inferior turbinates. Note the reactive
swelling of the mucosal lining of the ethmoids and left maxillary sinus to compensate for
the abnormally wide space.
Patients with wide nasal cavity syndrome suffer from a
variety of complaints: a feeling of nasal obstruction in spite
of normal breathing; nasal irritation and itching; headaches
and pressure feelings; radiating pain on inspiring cold air;
crusting; and minor blood loss. The severity of these
complaints varies considerably from person to person.
Some patients have only minor symptoms, whereas others
are real “nasal cripples.”
On examination, the nasal cavity is abnormally spacious,
lacking (part of) one or both turbinates. Mucosal pathology
varies greatly. In some patients, the mucosa is dry and pale
because of metaplasia; in others, it is red because of
chronic infection. Crusting may range from absent to
severe. The symptoms are caused by abnormal air currents
due to disturbed anatomy and loss of the mucosa and its
serous and mucus glands. In many cases, however, the
discrepancy between the degree of the anatomical
disturbance and the severity of the symptoms is difficult to
understand.
2.1.10Dry Nose Syndrome
Dry nose syndrome is found in primary and secondary
atrophic rhinitis. Primary atrophic rhinitis may occur as
part of a systemic syndrome or may be of unknown origin.
Secondary atrophic rhinitis is much more common. It is
mostly iatrogenic, resulting from a loss of normally
functioning mucosa following electrocoagulation,
chemocautery, or laser treatment of the inferior turbinates.
Septal surgery without proper septal reconstruction may be
an additional factor. Symptoms include nasal irritation,
itching, and a feeling of dryness. Some crusting and
epistaxis may also occur.
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2.1.11Cleft Lip– and Cleft Palate–Nose
A cleft lip and/or cleft palate is one of the most common
congenital anomalies. Its treatment is one of the most
difficult challenges to the maxillofacial and nasal surgeon.
The deformity consists of a unilateral or bilateral defect of
the upper lip, alveolar process of the maxilla, and/or palate.
Unilateral clefts are much more common than bilateral
clefts.
The incidence of cleft lip and palate varies considerably by
region and ethnic group. According to recent literature, the
incidence lies between 0.3 per million (Native Americans,
Japanese) and 2.5 per thousand (black Nigerians and South
Africans).
A positive family history can be found in about a quarter of
cases. External factors are assumed to play a causative role
in other cases. When they occur before the sixth week of
gestation, they may lead to a complete syndrome. When
occurring later, but before the 10th to 12th week, an
isolated palatal defect will occur (see Chapter ▶ 1, ▶
Developmental Phase).
In patients with a cleft lip, all nasal elements and adjacent
structures are more or less affected.
The bony and cartilaginous pyramid are asymmetrical and
lean slightly to the noncleft side (NCS; ▶ Fig. 2.26 and ▶ Fig.
2.27).
Fig. 2.26Cleft lip- and cleft palate-nose on the left side. The bony and cartilaginous
pyramid lean slightly to the NCS. The lobule is severely deformed: the dome and ala on
the CS are depressed, the alar base is lower, the nostril is more horizontal.
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Fig. 2.27Cleft lip- and cleft palate-nose on the left side. The bony pyramid leans to the
NCS, whereas the cartilaginous pyramid and lobule deviate to the CS. The lobule is
severely asymmetrical. The ala on the CS is flattened and displaced, and the lateral crus
of the lobular cartilage is lower, less convex, and located more caudally.
The piriform aperture is asymmetrical, the aperture on the
cleft side (CS) being lower and narrower. The anterior
nasal spine deviates to the CS or may be missing. The
premaxilla is severely deviated to the CS with its median
axis up to 40° (▶ Fig. 2.28).
Fig. 2.28Cleft lip- and cleft palate-nose on the left side. Skull. The piriform aperture on
the CS is lower and narrower. The anterior nasal spine and the premaxilla are strongly
deviating to the CS. A pronounced crest and spur are present on the CS. The bone of the
inferior turbinate on the CS is lower and more lateral than on the NCS. Photo courtesy
Prof. Pirsig.
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The lobule is deviated to the CS and strongly asymmetrical.
The tip is bifid and flat and deviates to the CS. The dome
and lateral crus on the CS are severely depressed, less
convex, and more caudally located; the ala is elongated,
flat, and displaced in a lateral and caudal direction; the
vestibule is narrow and has a more horizontal axis.
The columella is short, broad, and oblique. Its upper end
leans to the CS; its base is retracted. The medial crus on
the CS is somewhat displaced in a caudal direction and
looks shorter than the opposite medial crus (▶ Fig. 2.29).
Fig. 2.29Cleft lip- and cleft palate-nose on the left side. The lobule is severely
asymmetrical: the dome and lateral crus on the CS are depressed and rotated in an
anterior direction. The nostril is ovaloid and has an almost transverse axis. The vestibule
is narrow. The columella is short and deviating to the CS. The caudal septum is deviating
to the NCS.
The septum is severely deformed. Its caudal end is
dislocated to the NCS and may thereby narrow the
vestibule on this side. More posteriorly, the cartilaginous
septum, vomer, and perpendicular plate are strongly
deviated to the CS, obstructing the valve area and the nasal
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