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Mandibular Retrusion (Retroposition or
Retrognathia)
Retrusion of the mandible, or retrognathia, is a common
feature of the dolichocephalic skull. It is frequently seen in
Caucasians (▶ Fig. 2.38). Retroposition of the mandible
visually accentuates the prominence of the nasal pyramid.
In these patients, “let-down” of the pyramid is therefore
often combined with mentoplasty.
Fig. 2.38Retroposition of the mandible.
2.1.14Nasal Neuralgias
Nasal or sinus disease is the most common cause of facial
pain and headache. Branches of the palatine nerve become
irritated, producing pain and pressure sensations that may
be felt in a wide area of the head. It is customary for
laymen and doctors alike to suspect some kind of
“sinusitis.” In many cases, however, the cause is found in
the septum and the turbinates. Two syndromes may be
distinguished as follows:
1. Pterygopalatine neuralgia or Sluder syndrome
2. Anterior and/or posterior ethmoidal neuralgia
Pterygopalatine Neuralgia (Vidian Neuralgia or
Sluder Syndrome)
Branches of the pterygopalatine nerve (posterior–superior
and posterior–inferior lateral nasal branches or posterior
septal branches) become irritated by pressure or infection.
The most common symptoms are homolateraldeep pain or
pressure feelings localized paranasally and around the
orbit, sometimes radiating towards the forehead and the
back of the skull. It is often combined with increased
homolateral secretion and nasal blockage. This type of
cephalic neuralgia was first described as a specific entity
by Greenfield [290], [289], 1927) and is therefore often
referred to as Sluder syndrome. It is also called Vidian
neuralgia.
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Its most common cause is impaction of a septal deformity
(usually a spur) into the posterior part of the inferior
turbinate. Other causes may be a new growth, a foreign
body, or an infection of the posterior–inferior half of the
nasal cavity.
Diagnosis of pterygopalatine neuralgia is confirmed by the
immediate relief of symptoms when the pterygopalatine
ganglion is anesthetized (preferably with crystalline
cocaine on the tip of a cotton wool applicator; see ▶
Endonasal Block Anesthesia and ▶ Fig. 3.5). The more precisely
localized the anesthesia, the better this type of neuralgia
can be distinguished from other types, such as ethmoidal
neuralgia. If a septal impaction is suspected as the likely
cause of the Sluder-type of neuralgia, a test with local
decongestion may be tried before applying anesthesia. If
the pain stops when the turbinate is simply detached from
the septum, the pain can be attributed to the
septoturbinate contact. Septal surgery is often an effective
treatment.
Anterior (Posterior) Ethmoidal Neuralgia
A similar syndrome may occur when branches of the
anterior or posterior ethmoidal nerve are involved. Pain
and pressure feelings are then perceived in and around the
bony pyramid and nasal root, paranasally, medially, and
posteriorly in the homolateral orbit and the forehead.
Ophthalmic symptoms frequently occur, especially tearing.
The syndrome may then be called Charlin syndrome or
nasociliary neuralgia ([27]). Its most common cause is
obstruction of the middle nasal passage or the
infundibulum, as discussed and illustrated in the section on
middle meatus obstructive syndrome (see ▶ Middle Meatus
Obstructive Syndrome). Another variant of anterior ethmoidal
neuralgia is open roof syndrome.
2.2Nasal Symptoms—The Most Common
Deformities, Abnormalities, and
Anatomical Variations
The human nose is subject to a wide array of deformities,
abnormalities, and anatomical variations.
Deformity: Whether we are dealing with a deformity is
rarely a matter of discussion. Congenital malformations of
the nose like those in cleft-lip patients, nasal hypoplasia, or
bifidity are clearly deformities. The same applies to
acquired anomalies of the nose as may occur after trauma,
infection, or new growth. Deviated nose, saddle nose, open
roof, retracted columella, and septal deviation, to name a
few, are considered deformities.
Abnormality: An abnormality may be defined as a
“pathological anatomical change.” Frequently, an
abnormality implies functional disturbance. This is not
always the case, however. Generally, a slight posttraumatic
sagging of the cartilaginous dorsum, flaccid alae, or an
overprojected tip are abnormalities.
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Anatomical variation: Deciding when an anatomical
condition should be considered an anatomical variation
may be more difficult, as this is often a matter of personal
opinion. Many variations are, to a certain extent,
dependent on race, gender, or age, and have therefore to
be considered within the normal range.
2.2.1Pathology and Variations of Nasal
Dimensions
The human external nose may vary considerably in all its
dimensions. Interindividual differences are determined by
ethnic factors, gender, age, and pathological influences due
to injury and infection. We define these differences in terms
of: size (small–large), length (long–short), height,
prominence (prominent–low), and width (wide–narrow) (▶
Fig. 2.39).
Fig. 2.39Normal facial dimensions. T = trichion; N = nasion; S = subnasale; P =
pogonion. The distance T–N equals N–S equals S–P.
Long Nose (▶ Fig. 2.40)
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Fig. 2.40Long nose. The nasion–tip distance is abnormally large compared to the
trichion–nasion distance and subnasale–pogonion distance.
The distance nasion–tip is abnormally large, often in
combination with excessive height. The pyramid may be
prominent and narrow, and the tip is often drooping. The
nasolabial angle is more acute than average. A long nose
may be caused by genetic as well as endocrine factors. The
external nasal pyramid tends to lengthen with increasing
age. A long nose may also result from surgery when a
dorsal hump has been resected without shortening nasal
length.
Short Nose (▶ Fig. 2.41)
Fig. 2.41Short nose. The nasion–tip distance is abnormally small compared to the
trichion–nasion distance and subnasale–pogonion distance.
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The distance nasion–tip is shorter than normal. This is
always combined with diminished height. The pyramid is
generally wide and less prominent than normal. The
nasolabial angle is relatively large. A short nose is seen in
patients with congenital nasal hypoplasia or impaired nasal
growth. It may also occur after surgery where the nasal tip
has been upwardly rotated too much.
Prominent Nose (▶ Fig. 2.42)
The projection (prominence, salience) of the external nasal
pyramid is greater than normal. Usually, the nose is long
and narrow.
Fig. 2.42Prominent nose. The projection of the pyramid (the dorsum–nasal base line
distance) is larger than normal.
Low Nose (▶ Fig. 2.43)
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