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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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Asymmetries and abnormal dimensions of the face play a
major role in our perception. Thus, when examining nasal
deformities, abnormalities, and variations, we have to
analyze the nose in relation to the face. A normal, straight
nasal pyramid will only give the impression of being normal
and nondeviating when the face is symmetrical. The
projection of the nasal pyramid depends upon the
prominence of the forehead, maxilla, and especially the
chin. We use a caliper to take measurements of certain
nasal and facial dimensions as part of the examination
procedure (▶ Fig. 2.133). The most informative parameters
of the nose are height, length, width, and prominence. The
most important angles are the frontonasal and the
nasolabial angles. The most useful indices are the clinical
nasal index and the tip index.
Fig. 2.133A caliper is used to measure nasal dimensions and indices.
Proportions
The facial proportions may be visualized (and measured) by
drawing four horizontal and six vertical lines on the front
view photograph of the patient (see Chapter ▶ 1, ▶ Fig. 1.2,
and ▶ Fig. 1.3).
Angles
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The frontonasal and nasolabial angle may be drawn and
measured on the profile photograph (see ▶ Fig. 1.11a, b).
Dentition
Examining the patient’s dentition is an essential part of a
rhinological investigation. Special attention is paid to the
number and position of the incisor and canine teeth. When
elements in the upper jaw are missing, this may be
combined with a deformity of the premaxilla and the
anterior septum. Sometimes, a dislocated (canine) tooth is
present in the base of the septum. Trauma to the
premaxillary area in early childhood is a common cause of
malpositioning of the anterior upper teeth.
Dental occlusion is another aspect to be examined. Usually,
malocclusion disorders are due to a disturbance of the
maxillary–mandibular relationship. Indirectly, this has an
impact on the visual position of the external nasal pyramid
in the face (see also the section on facial syndromes (see ▶
Facial Syndromes). In patients with an evident dental
abnormality, referral to a maxillofacial surgeon is indicated.
Nasal surgery might then have to be preceded by
orthognathic surgery.
2.3.5Imaging
The position of the maxilla and the mandible (chin) in
relation to the other structures, in particular the external
nasal pyramid, may be analyzed on lateral and fronto-
occipital standard radiographs, or on standard
photographs. The procedure is described next.
Steps
A vertical line is dropped through the subnasale at a
right angle to the Frankfort horizontal line (line from
infraorbital margin to the upper margin of the bony
external ear canal). In the “ideal” face, this line will
touch the pogonion. If this is not the case, this indicates
retrusion or protrusion of the maxilla and/or mandible.
A second line is drawn at a tangent to the nasal
dorsum. The angle between this line and the vertical
line (nasofacial angle) is normally 30 to 40°. In a
prominent nose it is larger, in a low nose smaller.
A third line is drawn from the nasal tip to the pogonion.
The angle between this line and the nasal dorsal
line(nasomental angle) is normally 120 to 130°. In a
patient with mandibular retrusion or a prominent nasal
pyramid, this angle is smaller. Normally, the upper lip is
1 to 2 mm posterior to this line, and the lower lip 2 to 4
mm.
A fourth line is drawn at a tangent to the gnathion,
passing through the innermost curve at the junction of
the neck and submental area. Normally, this line forms
an angle (mentocervical angle) of 80 to 95° with the
vertical line and an angle of 110 to 120° with the
nasomental line.
For more general aspects of facial and nasal proportions, as
well as definitions of the various points, lines, and angles
used in nasal analysis, the reader is referred to Chapter ▶
1, ▶ Face.
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Radiographs
Standard radiographs have been the gold standard for
some eight decades in screening for facial trauma (orbital
floor, orbital rim, zygoma), nasal fractures, and diseases of
the paranasal sinuses. Nowadays, coronal CT scanning has
superseded standard radiography, as pathology and
anatomical variations can be imaged in greater detail
according to requirements. The recently introduced cone
beam CT scanning has proven an equally effective
technique with a smaller radiation load.
CT Scans
CT scanning has greatly improved rhinological diagnosis
and follow-up of treatment. This applies, first of all, to sinus
disease. However, in several nasal disorders, CT scans may
be of great help too. The following are well-known
examples:
Deformities of the bony and cartilaginous pyramid
(coronal and axial planes)
Septal pathology (coronal plane)
Turbinate anatomy (concha bullosa) and turbinate
pathology (coronal plane)
Complications of dorsal transplants and implants
(coronal and oblique planes)
Designing a custom-made prosthesis in patients with a
large septal perforation (sagittal plane)
▶ Fig. 2.134 presents an example of the value of a
preoperative CT scan in a patient with breathing
obstruction. The coronal scan shows severe septal
pathology with deviation of the cranial part of the
perpendicular plate to the right that is easily missed in
rhinoscopy, and compensatory hyperplasia of the left
inferior turbinate.
Fig. 2.134a, b CT scans may be very helpful in making a correct diagnosis. Note the
high deviation (arrow) of the perpendicular plate to the right, an abnormality that is
usually difficult to see on endoscopy. Also note the compensatory hypertrophy of the left
inferior turbinate. (Courtesy Prof. Clement.)
MRI
Magnetic resonance imaging is of limited value in
reconstructive nasal surgery except for demonstrating and
diagnosing soft-tissue swelling and tumors.
2.3.6Photographic Diagnosis and
Documentation
Taking color photographs in four or five standardized
positions is an essential step in analyzing the external nose,
face, and head. These photographs are obligatory for all
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patients in whom the appearance of the external pyramid is
(or may become) changed by surgery. In the first place,
they may be of great help in explaining the pathology and
the planned surgical treatment to the patient before the
final decision to go ahead is taken (see previous text).
Secondly, these photos are of utmost importance in
evaluating the result. Photographs are also important for
the follow-up of deformities and abnormalities.
Photographic follow-up of a traumatic septal pyramid
deformity during childhood and pubertal growth may be of
great help in decision-making. If the deformity increases
with time, we may decide to operate at an earlier age.
Similarly, photographic documentation is crucial for the
follow-up of scars, retractions, irregularities, or
postoperative sagging of the dorsum. Finally, if a
dissatisfied patient brings a lawsuit against the doctor, the
preoperative and postoperative photographs may be crucial
for the defense (see boxes: Indications for Preoperative and
[Usually 6 month-] Postoperative Photographs in Patients
Undergoing Surgery and Main Indications for Follow-up
Photography).
Indications for Preoperative and (Usually6-Months-) Postoperative Photographs in
Patients Undergoing Surgery
Before and after surgery
Adults:
pyramid and lobular surgery
surgery of adjacent structures
Children:
septal surgery
pyramid and lobular surgery
surgery of adjacent structures
Main Indications for Follow-up Photography
Follow-up of deformities, abnormalities, and
variations
Congenital:
nasal hypoplasia
cleft-lip syndrome
bifidity, etc.
Posttraumatic:
deviations
sagging and saddling
humps
irregularities, etc.
Postinfectious:
scars
saddling and sagging
retractions, etc.
Postsurgical:
infection
scars
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sagging and saddling
retractions
irregularities, etc.
Technique of Standard Nasal Photography
Medical photography must be performed according to
certain standards. Otherwise, the required information may
be distorted by technical variations, while postoperative
and preoperative photos are not comparable. The following
rules should be adopted.
Computerized Photography
Use of computer-stored images has become increasingly
popular recently. This way of storing data certainly offers
many practical advantages. However, digitized photographs
might be modified, and may therefore not be accepted as
proof in medicolegal cases. In some countries, courts have,
in fact, rejected computer images presented as proof by the
defending surgeon. Some surgeons use computer images to
analyze and discuss nasal deformities or variations with the
patient in the same way as standard photographs. However,
some also use the possibilities afforded by a computer to
demonstrate to the patient the modifications that might be
achieved by surgery. We would warn against this, as it may
give the patient the false impression that what can be done
on a computer screen can be duplicated by surgery. One of
the greatest mistakes a surgeon can make is to present a
patient with a printout of a computer-modified image.
Patient Positioning and Preparation
The patient sits up straight on a small, revolving stool.
Eyeglasses are removed. The front view photographs
are taken both with and without spectacles.
The forehead should be free of overhanging hair.
Earrings are removed.
Lighting and Background
The patient’s face is lit by indirect light to avoid shadow
effects. The background must be even and preferably
colored, either light blue or a light or medium shade of
green.
Requirements
All photographs have to be taken according to a number of
internationally accepted rules. Otherwise they may give a
false impression and cannot be compared.
Standard Positions
Generally, four standard positions are used:
1. Front view
2. Left side view
3. Right side view
4. Base view
Many surgeons also like to have a left and right oblique
view. These exposures provide extra information about the
lateral nasal wall. In patients with a deviated pyramid, a
view from above may also provide extra information.
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