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H. L. Verwoerd-Verhoef et al.
deviated septum of congenital, developmental, or
traumatic aetiology. Performing such procedures in
the paediatric age group is controversial because of
concerns about retarding or otherwise altering
nasal and midfacial growth patterns [1]. Children
as “category” include patients from 0years of age
to adolescence. In this period the nose is characterized by an increase in dimensions and an ongoing
development of the supporting midfacial skeleton.
Consequently, no “standard” anatomy exists for
children as for adults. The age-specic anatomy,
the vulnerability of the immature skeleton and the
morphogenetic processes providing a “normal”
adult nose, should be respected when nasal surgery
is considered for a child. The aim should be to
restore the anatomy in the short term, whereas a
“normal” facial prole at the adult age has to be
the—equally important—objective in the long run.
However, which developmental processes should
be restored and how? Anecdotal clinical evidence
in small series or single case reports suggests that
nasal trauma, septal infection or even childhood
septoplasty can cause severe morphological and
functional disturbances of the nose later in life. The
restriction of clinical observations is the temporariness without, in general, the possibility to follow
up the developmental processes for a longer period,
or to analyse the effects of various well-dened
injuries and treatment modalities in children of different age groups. Here comes the value of research
in experimental animals.
Experimental studies demonstrated the morphogenetic mechanisms which might be held
responsible for a normal development of the nose
and upper jaw (the inferior wall of the nose!) and
the developmental effects of lesions and surgical
interventions of various parts of the nasal skeleton. Clinical evidence, facial morphogenesis in
children, and the interaction between wound
healing, growth and surgical procedures, as studied in animal experiments, all contribute to the
current practice of nasal surgery in children.
The age-specic anatomy of the midface
makes rhinosurgery in children different
from the procedure in adults.
Knowledge of the age-specic anatomy and
developmental processes is essential for proper
diagnosis and treatment of midfacial lesions in
children. It became clear that the dimensional
aspects of nasal growth, the evolution of the
growth rate during childhood and the age at which
the growth spurt ends, are related to gender [2].
The growth rate of the facial skeleton (nose, upper
and lower jaw) is higher compared to that of the
brain skull. In the rst years of life the growth rate
is also faster, and only gradually decreases in
adulthood. The craniofacial ratio at birth is said to
be 8:1 compared to 4:1 at 5years of age and 2:1in
adulthood [3]. The human nasal septum is the
dominating structure to determine the size and
shape of the visible nose and, thus, inuences the
appearance of the face. The anatomy and dimensions of the nose are changing with increasing age.
The baby’s face acquires an adult prole. The anatomical development of the nose with tissue maturation of the cartilaginous and bony parts, including
their age-specic characteristics, are described
below as they have to be considered very important and studied extensively before treatment or
surgery is performed. Up to now, these morphogenetic processes in the septodorsal cartilage and in
the sutures of the nasal pyramid and maxilla have
been observed as more or less independent growth
centres. The effects of frequently occurring injuries of the midfacial skeleton on the further development of the face, however, point to a strong
correlation between the various parts. In an anatomical study on cleft, lip and palate it was phrased
by Hall and Precious as follows: “Growth of the
nasal septal cartilage outstrips the growth of other
skeletal and soft tissues in the midface to such an
extent that it is the pacemaker for growth of the
face and anterior portion of the skull” [4].
It appeared that the release of interlocked
stresses within the cartilage and the poor wound
healing after fractures or loss of septum cartilage
are key factors in maldevelopment of the midface, and also form a serious risk factor in surgical reconstruction at a young age [5, 6]. These
biological aspects of surgical intervention have to
be taken into account when the ultimate aim is to
restore the normal form and function of the nose
and midface.
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Up to three decades ago a review of the clinical literature reporting results of nasal trauma
and surgery in children demonstrated that denite conclusions were still hampered by various
elements such as a lack of differentiation for the
age of the patients at the moment of injury or surgery, a too short follow-up period after surgical
treatment and incomplete documentation of the
surgical procedures applied [6].
Since then several larger clinical studies have
been published presenting the results of a series
of young patients who presented a nasal disorder
and mostly underwent septoplasty without or
with other procedures in an endonasal or external
approach [7–15]. In most of these studies, the
documentation had been improved and the follow- up period was extended to sometimes several
years, however, with a very large dispersion
(scatter) and mean value. Nevertheless, the outcome of paediatric septoplasty in these studies is
varying from “not interfering with the normal
growing nasal process” [12] to “a solid appreciation of long-term outcomes and effects on growth
remain elusive” [16], which sounds as a conservative warning. An impeding factor in the interpretation of all these results described for children
may be that the moments of age at the surgery
have been added up from generally 4 years to
mid-10s in one group with a mean value. The
results of the surgery have never been studied or
measured (by anthropometry or cephalometry)
per age group for every year. Mostly the number
of patients in each category would then probably
be too small for statistics. Moreover, this could
explain that rhinoplasty in children is complicated by high revision and aesthetic dissatisfaction [13]. “Good results following surgery is no
guarantee for long-term satisfaction” [13]. A
variation in the analysis of these clinical reports
seems to have added to the confusion of tongues
in various review articles [17–19].
There is still work to do!
Studies in young experimental animals like
rabbits [20–23], guinea pigs [25, 24], rats [26],
ferrets [27], cats [28], dogs [29] and primates
[30, 31] have contributed substantially to understanding the effects of trauma and surgery on the
growing nasal and midfacial structures; observa-
tions in larger series of pure-bred mammals could
be dened by geometrical measurements and
data statistically processed. Despite the differences between human and animal anatomy, the
constituting elements of the facial skeleton show
sufcient signicant similarities to allow comparisons relevant to the notion of the pathophysiology of the human face and provide suggestions
for treatment. In growing rabbits as well as in
children the nose and upper jaw grow faster and
over a longer period than the brain skull.
36.1.2 The Facial Prole andNasal
Skeleton oftheNewborn
In the newborn, the dimensions of the splanchnocranium (maxilla, nasal pyramid, and mandible) are small in proportion to the size of the
neurocranium (brain skull)! The large dimensions of the latter are related to the rapid development of the brain during pregnancy which
continues into the rst years of life. The facial
prole of the neonate (Fig. 36.1) shows smaller
vertical dimensions of the midface, less frontal
projection of the nasal dorsum and a larger nasolabial angle compared to the facial proportions
in fully grown individuals [32].
In the newborn, the cartilaginous and bony
nasal skeleton demonstrate a few specic
aspects. Septal cartilage and upper lateral cartilages on both sides form the three-dimensional
septodorsal cartilage, a supporting structure for
the nasal dorsum resembling a T-bar conguration [33]. The cartilaginous septum is based on
the sphenoid (Fig. 36.2). The upper lateral cartilages extend under the nasal bones to merge with
the cartilaginous anlage of the anterior cranial
base. The nasal bones are brously connected in
the sutures to the frontal and maxillary bones. At
their ventral rim, the periosteum of the nasal
bones is rmly connected to the perichondrium
of the underlying upper lateral cartilages. The
nasal bones are the product of extra-cartilaginous ossication of cephalic mesenchyme. The
rst anlage of the vomer is also represented by
islands of mesenchymal bone formation reaching from palatal bone to cartilaginous septum
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P
A
a
b
P
A
Fig. 36.1 The facial prole of a 3-month-old boy (a) and
his father; (b) Note the proportional differences between
the facial and brain skull of father and son. The baby face
shows smaller vertical dimensions, a less frontal projection of the nose and a larger nasolabial angle
with extensions of ossifying mesenchyme along
both sides of the septum cartilage. Enchondral
ossication of the septum cartilage may be
observed as early as the rst months after birth
near the anterior cranial base [34]. The cartilaginous septum shows a specic pattern of thinner
and thicker zones; the thickness of the septum
was found to vary between 0.4 and 3.5mm. Two
areas of thick cartilage are extending from the
sphenoid in antero-superior direction to the nasal
dorsum (sphenodorsal zone) and the anterior
Fig. 36.2 A specimen of neonatal cartilaginous nasal
septum; (a) indentations at the border with the anterior
cranial base concur with ossied parts lost during preparation; (A) anterior and (P) posterior side; (b) Lateral radiograph of a human neonate including the nasal skeleton,
adjacent skull base and upper jaw; (A) cartilaginous nasal
septum, (B) lamina cribrosa, (C) vomeral wing, (D) anterior nasal spine, (E) palate, (F) sphenoid; (c) Schematic
representation of the thinner and thicker zones in the neonatal human septum (superior part of the septum, adjacent
to the anterior cranial base, is not included). The thinnest
frontal part (yellow, 400–500mu) is bounded by the columellar rim (light green, 500–1500mu); sphenodorsal and
sphenospinal zones of thicker cartilage (dark green-
brown, 1500–3000mu); sphenoid (black)
nasal spine (sphenospinal zone), respectively
(Fig.36.2c). The thinnest part is found anteriorly
between these two zones and the slightly thickened caudal rim.
a
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In young children the cartilaginous nasal
septum is based on the sphenoid, whereas
the upper lateral cartilages extend under the
nasal dorsum to merge with the cartilaginous cranial base. Dimensions and anatomical features change with increasing age.
In young rabbits, a similar pattern of thicker
and thinner areas has been demonstrated in the
elongated septum [35, 36]. The thicker areas play
a specic and important role in the postnatal
development of the nose and upper jaw as will be
b
discussed in the paragraph on acquired malformations of the septum. Also in young rabbits, the
septal and upper lateral cartilages form a T-bar,
based on the anterior skull base.
36.1.3 Midfacial Development
fromNeonate toAdolescent
503
In children, the development of the cartilaginous
nasal skeleton is a complex process including the
proliferation of chondroblasts, an increase of
intercellular matrix, tissue maturation, partial
regression, and enchondral ossication of the
septodorsal cartilage. The dimensional growth of
the septum cartilage shows its highest rate in the
newborn and is slowing down gradually after the
age of 2years [37]. From that time onwards formation of new cartilage continues but is balanced
by simultaneous loss of cartilage through enchondral ossication [38]. Mitotic activity of chondroblasts and expansion of the intercellular
matrix might compensate for the loss of cartilage
by ossication till the ratio between bony and
cartilaginous parts has been changed to its denite state (Fig.36.3). Consequently, the sagittal
dimensions of the bony perpendicular plate are
increasing relative to the cartilaginous part of the
septum [39]. The growing perpendicular plate
will intervene between septal cartilage and sphenoid. The septum cartilage is later rmly connected to the thickened caudal rim of the
perpendicular plate. The junction of the cartilaginous septum and perpendicular plate—an impor-
Fig. 36.3 The interface between septum cartilage (right)
and bony perpendicular plate (left); (a) active enchondral
ossication in a young child; (b) no signs of ossication in
the adult stage
tant surgical landmark—will change from an
intracranial position in young children to the
extracranial location at the anterior margin of the
nasal bones in adults. The basis of the septum
cartilage shifts from the sphenoid to the anterior
rim of the perpendicular plate (Fig.36.4a).
The vomeral bone which rst anlage was
already present in the neonate will develop into a
denite part of the osseous nasal skeleton [40].
The vomer is enclosing the basal rim of the septum cartilage by two bony layers (vomeral wings)
which converge inferiorly in the medial, unpaired
bony plate separating the inferior part of the nasal
cavities and extending in a posterior direction to
the choanal edge of the nasal septum. The
moment at which the ossifying front of the perpendicular plate should reach the vomeral wings
is not clearly dened and may even surpass the
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H. L. Verwoerd-Verhoef et al.
Lp
C
V
Fig. 36.4 Detail of a human nasal septum (at the age of 17
years); (a) Lateral radiograph with the overlap of vomeral
wing and perpendicular plate; (C) anterior skull base; (D)
lamina perpendicularis; (F) vomeral wing; (b) schematic
representation (in frontal sections) of various modalities of
age of 10years, while overlap between wings and
plate has been found in adolescence. Cartilage
may remain present in the bony canal formed by
vomeral wings and perpendicular plate (vomeral
tunnel) for a longer period and extend to the
sphenoid, as the sphenoid tail, but ultimately
ossify in most individuals. Asymmetry of the
vomeral wings (the ala on one side is larger than
on the other side) may be observed when the
sphenoid tail bulges out into one nasal cavity,
sometimes in combination with a vomeral spine
(Fig.36.4b). Variations in the septovomeral junction are very common and a symmetrical development is an exception rather than the rule. In a
study on human foetuses of 5months old, it was
observed by Takahashi that around 25% demonstrated an abnormality of the septovomeral junction which could increase to almost 40% at birth
[41]. These deformities were ascribed to “an
imbalance of the ‘overdeveloping’ septum (cartilage) and the pressure of the surrounding structures”, the last-mentioned being the developing
bony facial skeleton.
the septo-ethmoido-vomeral junction (after Takahashi
1987); (1) normal situation, Lp=lamina perpendicularis,
c=cartilage v=vomer; (2) asymmetrical development of
vomer and cartilage; (3) asymmetrical development of
vomer with formation of vomeral spine; (4) sphenoid tail
Progressive ossication of the septum cartilage
results in an expanding perpendicular plate starting from the area of the anterior cranial base into
the ventrocaudal direction. The ventral rim of the
perpendicular plate shifts gradually inferiorly
and, therefore, is in children not a reliable point of
orientation in relation to the anterior skull base.
The junction between cartilaginous septum, perpendicular plate and vomer may demonstrate considerable variation but is thought to have been
established between 10 and 14years of age.
The length of the upper lateral part of the dorsoseptal cartilage will be reduced on both sides to
nally around 5–8 mm. The progress of this
reduction shows individual variation. While the
dimensions of the nasal skeleton increase in size,
the relation between cartilaginous and bony parts
is going to be altered. This remodelling will result
in a more anterior position of the cartilaginous
part of the septum. It is an important issue which
should be understood by the doctor at the moment
of diagnosis and before treatment of the child
might be started.
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sutural growth contributes to the lengthening of
Anatomical data do not give information
pertinent to the developmental mechanisms. Animal experiments are necessary
to analyse these morphogenetic mechanisms and the way they are affected by
injury or surgery.
the upper jaw and continues till sexual maturity.
Also in young rabbits, the septodorsal cartilage
extends under the nasal bones to the anterior cranial base, later followed by a reduction of the posterior part of the cartilage leaving only the most
anterior part in situ. The cartilaginous septum
remains in direct contact with the sphenoid. Only
a small part will demonstrate ossication to form
36.1.4 Postnatal Development
oftheMidfacial Skeleton
inMammals
the perpendicular plate. Obvious differences compared to the human anatomy are demonstrated by
the vomer. The vomer is a product of mesenchy-
mal ossication along both sides of the cartilagiThe skulls of mammals demonstrate essentially
similar components (Fig.36.5). Various components however may show very different dimensions in different species. An example is a
proportion between the skeletal components of
the upper jaw. In the human skull the premaxilla
is small compared with the maxilla whereas in
rodents, like the rabbit, the anteroposterior
dimensions of the premaxilla exceed those of the
maxilla. In children, the osteogenic activity of the
premaxillo-maxillary suture is restricted to the
rst years of life contrary to rabbits in which
nous septum and between the palatal bone and the
inferior margin of the septum The cartilaginous
septum, anteriorly connected to the anterior nasal
spine, shows thinner and thicker parts similar to
those described for the human nasal septum
(Fig.36.6). An centro-anterior area of thin carti-
lage is surrounded by sphenodorsal and spheno-
spinal zones of thick cartilage and anteriorly
bordered by a slightly thickened anterior rim. In
growing rabbits it was demonstrated that the
“extra” growth of the nose and maxilla depends
primarily on the growth of the septodorsal carti-
505
a
b
*
*
Fig. 36.5 Lateral aspect of the rabbit septum and skull
(after removal of the right part of the nose and upper jaw);
(a) at the age of 4 and 24 weeks; (b) It demonstrates the
“extra” growth of the nasal skeleton and upper jaw up to
the adult stage, compared to the dimensional development
of the brain skull. *-* Line between lambdoid suture and
spheno-occipital suture. (A) cartilaginous nasal septum,
(B) nasal bone, (C) incisors, (D) molar complex, (E)
vomeral wing, (F) perpendicular plate
8 weeks
Fig. 36.6 Schematic presentation of regional differences
in thickness of the cartilaginous nasal septum in an
8-week-old rabbit. The sphenospinal zone of thick carti-
lage extends from the sphenoid to the anterior nasal spine,
whereas the sphenodorsal zone is extending under the
nasal dorsum. In rabbits the lower lateral cartilages have a
common medial crus, which is connected by a thin carti-
laginous membrane to the slightly thickened anterior rim
of the “real” cartilaginous sptum; this thickened rim and
the sphenodorsal and sphenospinal zones of thick carti-
lage enclose an area of very thin cartilage; light green:
50–250 mu, dark green:250–450 mu, light red 450–
650mu, dark red 650–850mu
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Fig. 36.7 Graphic representation of the ‘extra’ growth of
the midfacial skeleton (with grid code) of the rabbit skulls
between 4 and 24 weeks after birth; the line connecting
lambdoid suture and the spheno-occipital suture (viz. Fig.
36.5a ) has been made equal for both series (n=20); elon-
gation of the upper jaw and the nose and forward shift of
the molar complex result in the adult proportions between
facial and brain skull
lage (Fig.36.7). The sphenodorsal zone of thicker
cartilage is responsible for lengthening the upper
part of the T-bar, the upper lateral cartilages, and
indirectly of the overlying nasal bones. These
upper laterals were found to stabilise the growing
septum cartilage in a median position. Also in the
rabbit, the extension of the lateral cartilages under
the nasal bones will be gradually reduced by
ongoing regression (Fig. 36.8). Enlargement of
the sphenospinal zone results in an increase in
length and thus, the gradual shifting of the lower
part of the septum and upper jaw. In the rabbit, the
perpendicular plate will be limited to the most
posterior part of the septum, whereas the majority
of the septum remains cartilaginous. Also in the
mouse, the cartilaginous septum increases in
length much more rapidly than could be explained
by caudal growth, implying that interstitial expansion is the more important contributor to septum
development [42]. Equally important as the septodorsal cartilage is for the growing midface, are the
sutures and their bone formation for the facial
skeleton, the nose included.
36.1.5 Dimensional Growth
oftheNose andMaturation
Post-mortem anatomical studies suggested a
phase of rapid growth directly after birth with a
gradual deceleration after 5years with the great-
H. L. Verwoerd-Verhoef et al.
Fig. 36.8 Schematic representation of the regression of
the upper lateral cartilage from (a) 4 to (b) 24 weeks; the
left nasal bone is removed (courtesy of Dr R.M.L.
Poublon)
est velocity in the rst 2 years [37, 43].
Conclusions drawn from a study in the Aegean
region of Turkey revealed that nasal height and
nasal bridge length reached full maturation in
females already at 12years of age and in boys at
around 15years [44]. Nasal growth has further
been studied by measuring cohorts of children
and calculating “standards” for various age
groups, differentiating between boys and girls.
Next to these horizontal studies, a few vertical
studies have been published based on measure-
ments of the same child at increasing ages. Such
a vertical study demonstrated in boys a period of
accelerated growth, most frequently observed
around the age of 13 years [2]. In young girls
periods of accelerated growth were found to
occur between the age of 6 and 8years. Growth
spurts have not been demonstrated in horizontal
studies including large cohorts of children. In the
last two decennia most data on postnatal growth
of the maxilla and the nose have been derived
from anthropometric or lateral cephalographs in
children of 7 years and older [2, 45–47]. In a
more recent review, the steepest descending slope
of midfacial growth velocity is reported to take
place at the average age of 13.4years for adoles-
cent girls and 14.7 years for boys [48]. It was
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suggested that 98% of white, adolescent girls are
“nasally mature” at the age of 15.8 years and
98% of the boys at the age of 16.9years.
36.2 Pathophysiology
oftheGrowing Nasal
Skeleton
36.2.1 Congenital Anomalies
507
36.2.1.1 Midfacial Clefts
andtheNasal Septum
Craniofacial growth is a dynamic process balancing form and function. This equilibrium is
easily disturbed at various levels by passive or
active change of one of the mechanisms
involved, prenatally or postnatally. The impact
of the interaction with the adhering muscles on
the developing midfacial skeleton has been recognized in recent years [50, 4, 49]. A spectrum
of midfacial malformations may be observed as
part of a syndrome or as solitary deformity
which may point to an interaction between the
growth of the nasal septum and the premaxillamaxilla. One of the most well-known congenital
facial deformities is the cleft lip, alveolus and
palate. In adult human skulls with facial clefts,
which were known to be untreated, a specic
pattern of growth disturbances could be
observed [52, 51]. Unilateral clefts showed a
deviation of the premaxilla to the non-cleft side,
whereas the maxillary part on the cleft side had
collapsed medially and fell behind compared to
the non-cleft side (retrognathism). In addition,
these skulls showed a specic malformation of
the nasal septum with (a) a deviation of the perpendicular plate to the cleft side and (b) a disjunction between the perpendicular plate and
vomer (Fig.36.9). The vomer, only connected to
the palatal margin of the cleft, tends to a more
horizontal position to meet the deviated perpendicular plate, suggesting a broadening of the
nasal oor on the non-cleft side. From this
study, it was concluded that these growth anomalies of the maxilla and nasal framework were
part of a cleft syndrome, specic for each type
of cleft [40, 53]. The collapse of the upper alve-
Fig. 36.9 Caudal view of a human skull with unilateral
cleft of alveolus and palate (Dept. of Anatomy and
Embryology, Amsterdam UMC). The maxillary segment
on the cleft side demonstrates a medial collapse and a ret-
roposition (asymmetrical position of the left and right
tuber maxillae); deviation of vomer and premaxilla to the
non-cleft side
olar arch and maxillary retrognathism were also
observed in adult members of a North-Borneo
tribe who were born with cleft lip, alveolus and
palate, and did not undergo surgical treatment
[54]. In a study on lateral cephalograms of
untreated unilateral cleft patients with superim-
posed images of cleft and non-cleft sides, the
abnormal position of the maxilla could not be
conrmed, most probably due to the over pro-
jection of the non-affected side [55].
Whether a combination of midfacial anomalies associated with a cleft alveolus and palate
might represent a syndrome of craniofacial
anomalies developing as a reaction to a cleft, was
investigated in growing rabbits [56]. Unilateral
clefts of the alveolus and palate, produced surgically in young growing rabbits, appeared to affect
the further development of the nose and (pre)
maxilla into adulthood (Fig.36.10a). On the cleft
side the molar complex, lacking a connection
with the growing septum, does not move forward
and will show—in the adult stage—a retroposition (retrognathism) compared to the non-cleft
side. Here, the premaxilla, maxilla and nasal
bones will grow to normal length, and gradually
rotate and deviate to the non-cleft side as previously reported for human skulls [52]. The results
of these animal experiments indicate that the cleft
syndrome as identied in ‘untreated’ human
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Fig. 36.10 Caudal aspect
of the skulls of adult
rabbits (24 weeks of age)
with maldevelopment
following surgical
procedures at the age of 4
weeks; (a) following a
surgical execution of an
unilateral cleft lip and
alveolus (resection of the
premaxilla-maxillary
suture): deviation of the
premaxilla from the
midline, retroposition of
the maxilla, zygoma and
pterygoid process on the
cleft side; (b) after a
similar cleft has been
made and closed by
primary osteoplasty:
marked deviation to the
operated side with
shortening of the upper
jaw, anteroposition of the
maxilla including molar
complex, zygoma and
pterygoid process
ab
skulls with facial clefts should be considered an
adaptation to the altered developmental mechanics in the developing midfacial skeleton.
The interaction between the growing cartilaginous and bony skeleton is modied
when midfacial sutures are missing as in
the presence of facial clefts; similar cleft
syndromes were found in animals and
untreated patients.
Another interesting observation has been done
when in young rabbits the premaxillary- maxillary
suture was resected and replaced by non-sutural
bone (Fig.36.10b). Following this intervention,
normal lengthening of the ipsilateral upper jaw
failed. Secondary effects were a progressive
deviation of the premaxilla to the non-growing
side and an excessive forward shift of the molar
complex on the operated side. These observations
conrm disappointing midfacial development as
observed after osteoplasty of an alveolar cleft in
young children. The outcome of the abovementioned experiments refers to the role of the
cartilaginous nasal septum in the postnatal development of the upper jaw. The growing and
lengthening of the cartilaginous nasal septum,
connected on both sides to the premaxillamaxilla, seems to be responsible for the lengthening of the upper jaw and secondly, for a shift in
the anterior direction of the upper jaw relative to
the cranial base. In the presence of a unilateral
cleft, the “mechanical” balance between both
sides is disturbed.
Although the results of orthodontic and surgical treatment of facial clefts are improving, the
secondary cleft nose in these patients can demonstrate some of the following features: asymmetry
of the tip, columella, nostril, ala and nostril oor;
deection of the caudal part of the septum carti-
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509
lage to the non-cleft side; stenosis of the vestibule on the cleft side; hypoplasia of the maxilla
on the cleft side; the variable collapse of the maxilla with asymmetry of the piriform aperture;
underdevelopment of the maxilla with retroposition of the anterior nasal spine; deviation of the
cartilaginous and bony nasal dorsum; and deviation of the posterior part of the nasal septum to
the cleft side [57].
36.2.1.2 Congenital Malformation
oftheNose
Nasal congenital anomalies are extremely rare
and range from bidity of the nasal tip or dorsum
to nasal aplasia with or without proboscis [50].
Reports on nasal dysplasia, which is mostly indicating a unilateral malformation, are scattered
through the literature. The nasal cavity is missing
and pneumatization of the maxillary, ethmoidal
and frontal sinuses has failed. Exploration reveals
no cartilage, but just solid bone. The affected half
of the maxilla is hypoplastic and regularly associated with other malformations such as cleft lip,
palate or coloboma. The last variety to be mentioned is a duplication of the nasal dorsum, which
can occur in different forms and as part of a syndrome (Fig.36.11).
36.2.2 Acquired Anomalies
oftheNose
36.2.2.1 The Nose oftheNeonate
Various studies refer to the importance of the
nasal septum for midfacial development. In
humans, intrauterine exposure to warfarin
appeared to cause early calcication of the septal
cartilage; subsequent nasal and midfacial hypoplasia was demonstrated in a cephalometric
study, suggesting that even in utero midfacial
growth is retarded by interference with the nasal
septum [58]. In another anatomical study, the
morphological interaction between the nasal septum and nasofacial skeleton was found to be correlated and maintained throughout ontogeny
[49]. The nasal septal cartilage was demonstrated
to be the key growth factor.
The neonate’s nose may show a slight or more
pronounced deviation, with luxation of the lower
septal border into the nasal cavity, acquired during the passage through the birth canal
(Fig. 36.12). In most cases, this anomaly will
restore spontaneously but infrequently the deformity has to be corrected by manipulation of the
neonatal nasal septum which is still mostly cartilaginous from sphenoid to the columella. Already
a
Fig. 36.11 Congenital anomalies of the nose; (a)
Incomplete fusion of the left and right anlage of the cartilaginous and bony nasal skeleton in a 3-year-old girl and
b
(b) an adult man; (c) Under development of the cartilaginous and bony nasal pyramid
c
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