The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
endonasal endoscopic approach. In our case, the lesion was in the middle cranial fossa, relatively small, anterior to the cavernous sinus, and in close proximity to a cavernous segment of ICA (Fig. 2). Due to a high-volume blood leak during excision of the posterior wall, the wall of the cyst was left behind to avoid complications. The endonasal endoscopic approach allowed reliable access to the cyst and provided a large drainage window for endoscopic follow-up. At 1-year follow-up, no recurrence occurred. Although vertigo was reported due to rupture of the dermoid cyst in parasellar region,17 there was no relationship between vertigo and the dermoid cyst in our case. Nevertheless, the complaint of subjective vertigo resolved after surgical treatment. In conclusion, although dermoid cysts can be asymptomatic until reaching large sizes, they can cause severe symptoms when ruptured through the subarachnoid space and ventricular system. CT and MRI have high accuracy for diagnosis. Lipoma, epidermoid cyst, arachnoid cyst, craniopharyngioma, and teratoma should be considered in the differential diagnosis. Suppression of lipoma in fat-suppressed sequences and uniform visualization are important features for differentiating these lesions from dermoid cysts. The treatment of dermoid cysts is surgical excision; however, complete excision may not be possible due to adhesion to surrounding structures. Endonasal endoscopic removal of appropriate middle cranial fossa lesions is a recent advance in the extended applications of sinus surgery, allowing for less-invasive procedures with lower morbidity.
REFERENCES 1. Lunardi P, Missori P. Supratentorial dermoid cysts. J Neurosurg 1991;75:262–266 2. Smith AS, Benson JE, Blaser SI, et al. Diagnosis of ruptured intracranial dermoid cyst: value of MR over CT. AJNR Am J Neuroradiol 1991;12:175–180 3. Karabulut N, Oguzkurt L. Tetraventricular hydrocephalus due to ruptured intracranial dermoid cyst. Eur Radiol 2000;10:1810–1811 4. Liu JK, Gottfried ON, Salzman KL, et al. Ruptured intracranial dermoid cysts: clinical, radiographic, and surgical features. Neurosurgery 2008;62:377–384 5. Altay H, Kitis¸ O, Calli C, et al. A spinal dermoid tumor that ruptured into the subarachnoidal space and syrinx cavity. Diagn Interv Radiol 2006;12:171–173 6. Wilms G, Casselman J, Demaerel P, et al. CT and MRI of ruptured intracranial dermoids. Neurolradiology 1991;33:149–151 7. Osborn AG, Blaser SI, Salzman KL, et al. Diagnostic Imaging: Brain. 2nd ed. Canada: Friesens; 2004:1-22-25 8. Gualdi GF, Di Biasi C, Trasimeni G, et al. Unusual MR and CT appearance of an epidermoid tumor. AJNR Am J Neuroradiol 1991;12:771–772 9. Kallmes DF, Provenzale JM, Cloft HJ, et al. Typical and atypical MR imaging features of intracranial epidermoid tumours. AJR Am J Roentgenol 1997;169:883–887 10. Fujimaki T, Matsutani T, Funada N, et al. CT and MRI features of intracranial germ cell tumors. J Neurooncol 1994;19:217–226 11. Ageshio N, Shimono T, Goto T, et al. Imaging appearance of petrous apex dermoid cysts containing little or no fat. Jpn J Radiol 2013;31:133–137 12. Tsuchiya K, Mizertani Y, Hachiya J. Preliminary evaluation of fluid attentuated inversion recovery MR in the diagnosis of intracranial tumors. AJNR 1996;17:1081–1086 13. Akdemir G, Dag˘liog˘lu E, Ergu¨ngo¨r MF. Dermoid lesion of the cavernous sinus: case report and review of the literature. Neurosurg Rev 2004;27:294–298 14. Tun K, Celikmez RC, Okutan O, et al. Dermoid tumour of the lateral wall of the cavernous sinus. J Clin Neurosci 2008;15:820–823 15. Schuster D, Riley KO, Cure JK, et al. Endoscopic resection of intracranial dermoid cysts. J Laryngol Otol 2011;125:423–427 16. Du¨z B, Secer HI, Tosun F, et al. Endoscopic endonasal resection of a midline intradural frontobasal dermoid tumour. Minim Invasive Neurosurg 2007;50:363–366 #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
17. Asil K, Gunduz Y, Ayhan LT, et al. Spontaneous rupture of intracranial dermoid tumor in a patient with vertigo. Computed tomography and magnetic resonance imaging findings. Pol J Radiol 2013;78:79–82
Secondary Improvement in Static Facial Reanimation Surgeries: Increase of Nasal Function Gurkan Kayabasoglu, MD and Alpen Nacar Objective: The aim of this study was to measure the effect of the static reanimation operation administered to patients with facial paralysis on nasal function area by comparing patients’ preoperative and postoperative subjective perception of the nasal airflow. Materials and Method: We applied the Nasal Obstruction Symptom Evaluation (NOSE) scale to 13 patients who underwent static reanimation because of facial palsies, both preoperatively and postoperatively, and results were compared statistically. The changes in nasal base angulation were recorded and compared based on the photographs of patients taken before and after the surgery. Results: Following the static reanimation operation, 76% (10/13) of the patients reported a subjective improvement in the nasal airflow, whereas 24% (3/13) did not report any change. Mean preoperative and postoperative NOSE scale scores were 66.92 9.90 and 36.15 9.61, respectively. The change in mean NOSE scale score was statistically significant (P < 0.001). In the preoperative and postoperative comparison of the photographs taken from the front view of the patients, a decreased nasal base angulation compared with preoperative period was detected in 8 (61.6%) patients. Conclusions: A statistically significant increase in subjective perception about nasal function was observed after the static facial reanimation; however, it is not certain whether this effect can be considered persistent. Long-term studies conducted on a larger patient population will provide beneficial results. Key Words: Facelift, facial paralysis, nasal obstruction, nose, rehabilitation
T
he anatomy of the nasal valve was first described by Mink in 1903, and Kasperbauer and Kern made a further distinction
From the Sakarya University, Faculty of Medicine, Department of Otorhinolaryngology, Sakarya, Turkey. Received July 24, 2014. Accepted for publication February 3, 2015. Address correspondence and reprint requests to Gurkan Kayabasoglu, MD, Assistant Professor, Adnan Menderes Cad. No 145 Adapazari, Sakarya 54100, Turkey; E-mail: [email protected] This study was presented at 11th International Otolaryngology, Head and Neck Surgery Congress, April 2014, Ankara, Turkey. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001769
e335
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
FIGURE 1. Demonstration of the Cottle maneuver on the left side of the patient and facelifting on the right side of the patient.
FIGURE 2. Vectors for static reanimation suspension sutures.
between the nasal valve ‘‘angle’’ and nasal valve ‘‘area,’’ considering these two as distinct conceptual entities.1 As the nasal valve has the narrowest cross-sectional area in the nasal cavity, it is the part of the nasal anatomy that most commonly leads to airway obstruction, which primarily restricts the nasal airflow. Anatomically, nasal valve is composed of the most caudal part of the junction of nasal septum, upper lateral cartilages, inferior concha, and soft tissues in the piriform aperture. The airflow passing through the nose during breathing exerts a pressure on the surrounding tissues. According to Poiseuille law, the velocity of the flow passing through the canal increases with decreasing canal diameter. Based on the Bernoulli principle, liquids and gases with increased velocity exert a negative pressure on their environment. Therefore, the airflow accelerates in case of a narrower nasal valve and accelerated airflow increases the negative pressure on the nasal walls, leading to more collapse in this area.1,2 The Cottle maneuver is a physical examination method for internal nasal valve evaluation in which the midface and cheeks are pulled superolaterally by the examiner. It is done to assess whether patients can breathe more easily with the widening of the nasal valve because of the effect of this maneuver. This examination technique demonstrates the dilation of the narrow nasal valves through surgery, and also demonstrates the targets in face-lifting operations (Fig. 1).3,4 Air must pass through the nose with certain dynamics and velocity for the nose to best accomplish its physiologic function. Small changes in the size of the nasal valve can result in large changes to the surface area and can affect the airway resistance. Paranasal muscles dilate the nasal valve and contribute to decrease airway resistance, especially during inspiration. All paranasal muscles are innerved by facial nerve4–6; thus, it is not surprising that facial nerve paralysis often leads to nasal obstruction. In facial paralysis, both passive and involuntary muscle movements and active and voluntary muscular movements, are affected. Therefore, muscular tone decreases and superficial and deep facial tissues sag down as a result of the effect of gravity. The static facial reanimation method used in our study does not cause a direct effect on the nasal muscles or facial nerve functions; the gain obtained is a result of the correction of both the inferior displacement of the nasal base (because of gravity) and inferomedial displacement of alar area by the vector applied to superolateral part. This then leads to dilation of the nostrils and via the changes in airflow dynamics (an increase in canal diameter leading to a decrease in flow velocity and subsequent decrease in negative pressure), a dilation of the internal nasal valve area, similar to the workings of the Cottle maneuver. In this study, we aim to evaluate secondary nasal functional benefits in patients with facial paralysis after static facial reanimation.
Patients with Bell palsy as the etiology of their facial paralysis were included in the study. Exclusion criteria included patients with systemic granulomatous diseases, patients who had a history of radiotherapy to the head/neck region, and patients with coagulopathies. After obtaining the informed consent, patients were asked to complete the Nasal Obstruction Symptom Evaluation (NOSE) form pre- and postoperatively to assess breathing quality. Subjective assessments of complaints related to stuffy nose (1—nasal congestion or stuffiness, 2—nasal blockage or obstruction, 3—trouble breathing through the nose, 4—trouble sleeping, 5—unable to get enough air through the nose during exercise or exertion) were evaluated and scored as 0 (none) to 4 (very severe) points. Postoperative scores for at least 6 month were analyzed and statistically compared with preoperative scores. In addition to classical deep plan facelift procedure, a 2-cm-long incision was done to nasolabial sulcus. After orbicularis oris muscle modiolus was identified, 2 different 2–0 polypropylene sutures were passed from the oral commissure modiolus and an area of nasolabial sulcus near the nasal base. Those sutures and tissues were suspended and finally fixed to a hole that was drilled through zygomatic bone arch (Fig. 2). Preoperative and postoperative photographs were evaluated, and alar base levels and angulations were measured and compared. A Kolmogorov-Smirnov test was used to evaluate the distribution of variables, and a 2-paired sample t-test was used for the NOSE scale comparison. The NOSE scales were presented as the mean standard deviation; a P-value
Volume 26, Number 4, June 2015
endonasal endoscopic approach. In our case, the lesion was in the middle cranial fossa, relatively small, anterior to the cavernous sinus, and in close proximity to a cavernous segment of ICA (Fig. 2). Due to a high-volume blood leak during excision of the posterior wall, the wall of the cyst was left behind to avoid complications. The endonasal endoscopic approach allowed reliable access to the cyst and provided a large drainage window for endoscopic follow-up. At 1-year follow-up, no recurrence occurred. Although vertigo was reported due to rupture of the dermoid cyst in parasellar region,17 there was no relationship between vertigo and the dermoid cyst in our case. Nevertheless, the complaint of subjective vertigo resolved after surgical treatment. In conclusion, although dermoid cysts can be asymptomatic until reaching large sizes, they can cause severe symptoms when ruptured through the subarachnoid space and ventricular system. CT and MRI have high accuracy for diagnosis. Lipoma, epidermoid cyst, arachnoid cyst, craniopharyngioma, and teratoma should be considered in the differential diagnosis. Suppression of lipoma in fat-suppressed sequences and uniform visualization are important features for differentiating these lesions from dermoid cysts. The treatment of dermoid cysts is surgical excision; however, complete excision may not be possible due to adhesion to surrounding structures. Endonasal endoscopic removal of appropriate middle cranial fossa lesions is a recent advance in the extended applications of sinus surgery, allowing for less-invasive procedures with lower morbidity.
REFERENCES 1. Lunardi P, Missori P. Supratentorial dermoid cysts. J Neurosurg 1991;75:262–266 2. Smith AS, Benson JE, Blaser SI, et al. Diagnosis of ruptured intracranial dermoid cyst: value of MR over CT. AJNR Am J Neuroradiol 1991;12:175–180 3. Karabulut N, Oguzkurt L. Tetraventricular hydrocephalus due to ruptured intracranial dermoid cyst. Eur Radiol 2000;10:1810–1811 4. Liu JK, Gottfried ON, Salzman KL, et al. Ruptured intracranial dermoid cysts: clinical, radiographic, and surgical features. Neurosurgery 2008;62:377–384 5. Altay H, Kitis¸ O, Calli C, et al. A spinal dermoid tumor that ruptured into the subarachnoidal space and syrinx cavity. Diagn Interv Radiol 2006;12:171–173 6. Wilms G, Casselman J, Demaerel P, et al. CT and MRI of ruptured intracranial dermoids. Neurolradiology 1991;33:149–151 7. Osborn AG, Blaser SI, Salzman KL, et al. Diagnostic Imaging: Brain. 2nd ed. Canada: Friesens; 2004:1-22-25 8. Gualdi GF, Di Biasi C, Trasimeni G, et al. Unusual MR and CT appearance of an epidermoid tumor. AJNR Am J Neuroradiol 1991;12:771–772 9. Kallmes DF, Provenzale JM, Cloft HJ, et al. Typical and atypical MR imaging features of intracranial epidermoid tumours. AJR Am J Roentgenol 1997;169:883–887 10. Fujimaki T, Matsutani T, Funada N, et al. CT and MRI features of intracranial germ cell tumors. J Neurooncol 1994;19:217–226 11. Ageshio N, Shimono T, Goto T, et al. Imaging appearance of petrous apex dermoid cysts containing little or no fat. Jpn J Radiol 2013;31:133–137 12. Tsuchiya K, Mizertani Y, Hachiya J. Preliminary evaluation of fluid attentuated inversion recovery MR in the diagnosis of intracranial tumors. AJNR 1996;17:1081–1086 13. Akdemir G, Dag˘liog˘lu E, Ergu¨ngo¨r MF. Dermoid lesion of the cavernous sinus: case report and review of the literature. Neurosurg Rev 2004;27:294–298 14. Tun K, Celikmez RC, Okutan O, et al. Dermoid tumour of the lateral wall of the cavernous sinus. J Clin Neurosci 2008;15:820–823 15. Schuster D, Riley KO, Cure JK, et al. Endoscopic resection of intracranial dermoid cysts. J Laryngol Otol 2011;125:423–427 16. Du¨z B, Secer HI, Tosun F, et al. Endoscopic endonasal resection of a midline intradural frontobasal dermoid tumour. Minim Invasive Neurosurg 2007;50:363–366 #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
17. Asil K, Gunduz Y, Ayhan LT, et al. Spontaneous rupture of intracranial dermoid tumor in a patient with vertigo. Computed tomography and magnetic resonance imaging findings. Pol J Radiol 2013;78:79–82
Secondary Improvement in Static Facial Reanimation Surgeries: Increase of Nasal Function Gurkan Kayabasoglu, MD and Alpen Nacar Objective: The aim of this study was to measure the effect of the static reanimation operation administered to patients with facial paralysis on nasal function area by comparing patients’ preoperative and postoperative subjective perception of the nasal airflow. Materials and Method: We applied the Nasal Obstruction Symptom Evaluation (NOSE) scale to 13 patients who underwent static reanimation because of facial palsies, both preoperatively and postoperatively, and results were compared statistically. The changes in nasal base angulation were recorded and compared based on the photographs of patients taken before and after the surgery. Results: Following the static reanimation operation, 76% (10/13) of the patients reported a subjective improvement in the nasal airflow, whereas 24% (3/13) did not report any change. Mean preoperative and postoperative NOSE scale scores were 66.92 9.90 and 36.15 9.61, respectively. The change in mean NOSE scale score was statistically significant (P < 0.001). In the preoperative and postoperative comparison of the photographs taken from the front view of the patients, a decreased nasal base angulation compared with preoperative period was detected in 8 (61.6%) patients. Conclusions: A statistically significant increase in subjective perception about nasal function was observed after the static facial reanimation; however, it is not certain whether this effect can be considered persistent. Long-term studies conducted on a larger patient population will provide beneficial results. Key Words: Facelift, facial paralysis, nasal obstruction, nose, rehabilitation
T
he anatomy of the nasal valve was first described by Mink in 1903, and Kasperbauer and Kern made a further distinction
From the Sakarya University, Faculty of Medicine, Department of Otorhinolaryngology, Sakarya, Turkey. Received July 24, 2014. Accepted for publication February 3, 2015. Address correspondence and reprint requests to Gurkan Kayabasoglu, MD, Assistant Professor, Adnan Menderes Cad. No 145 Adapazari, Sakarya 54100, Turkey; E-mail: [email protected] This study was presented at 11th International Otolaryngology, Head and Neck Surgery Congress, April 2014, Ankara, Turkey. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001769
e335
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
FIGURE 1. Demonstration of the Cottle maneuver on the left side of the patient and facelifting on the right side of the patient.
FIGURE 2. Vectors for static reanimation suspension sutures.
between the nasal valve ‘‘angle’’ and nasal valve ‘‘area,’’ considering these two as distinct conceptual entities.1 As the nasal valve has the narrowest cross-sectional area in the nasal cavity, it is the part of the nasal anatomy that most commonly leads to airway obstruction, which primarily restricts the nasal airflow. Anatomically, nasal valve is composed of the most caudal part of the junction of nasal septum, upper lateral cartilages, inferior concha, and soft tissues in the piriform aperture. The airflow passing through the nose during breathing exerts a pressure on the surrounding tissues. According to Poiseuille law, the velocity of the flow passing through the canal increases with decreasing canal diameter. Based on the Bernoulli principle, liquids and gases with increased velocity exert a negative pressure on their environment. Therefore, the airflow accelerates in case of a narrower nasal valve and accelerated airflow increases the negative pressure on the nasal walls, leading to more collapse in this area.1,2 The Cottle maneuver is a physical examination method for internal nasal valve evaluation in which the midface and cheeks are pulled superolaterally by the examiner. It is done to assess whether patients can breathe more easily with the widening of the nasal valve because of the effect of this maneuver. This examination technique demonstrates the dilation of the narrow nasal valves through surgery, and also demonstrates the targets in face-lifting operations (Fig. 1).3,4 Air must pass through the nose with certain dynamics and velocity for the nose to best accomplish its physiologic function. Small changes in the size of the nasal valve can result in large changes to the surface area and can affect the airway resistance. Paranasal muscles dilate the nasal valve and contribute to decrease airway resistance, especially during inspiration. All paranasal muscles are innerved by facial nerve4–6; thus, it is not surprising that facial nerve paralysis often leads to nasal obstruction. In facial paralysis, both passive and involuntary muscle movements and active and voluntary muscular movements, are affected. Therefore, muscular tone decreases and superficial and deep facial tissues sag down as a result of the effect of gravity. The static facial reanimation method used in our study does not cause a direct effect on the nasal muscles or facial nerve functions; the gain obtained is a result of the correction of both the inferior displacement of the nasal base (because of gravity) and inferomedial displacement of alar area by the vector applied to superolateral part. This then leads to dilation of the nostrils and via the changes in airflow dynamics (an increase in canal diameter leading to a decrease in flow velocity and subsequent decrease in negative pressure), a dilation of the internal nasal valve area, similar to the workings of the Cottle maneuver. In this study, we aim to evaluate secondary nasal functional benefits in patients with facial paralysis after static facial reanimation.
Patients with Bell palsy as the etiology of their facial paralysis were included in the study. Exclusion criteria included patients with systemic granulomatous diseases, patients who had a history of radiotherapy to the head/neck region, and patients with coagulopathies. After obtaining the informed consent, patients were asked to complete the Nasal Obstruction Symptom Evaluation (NOSE) form pre- and postoperatively to assess breathing quality. Subjective assessments of complaints related to stuffy nose (1—nasal congestion or stuffiness, 2—nasal blockage or obstruction, 3—trouble breathing through the nose, 4—trouble sleeping, 5—unable to get enough air through the nose during exercise or exertion) were evaluated and scored as 0 (none) to 4 (very severe) points. Postoperative scores for at least 6 month were analyzed and statistically compared with preoperative scores. In addition to classical deep plan facelift procedure, a 2-cm-long incision was done to nasolabial sulcus. After orbicularis oris muscle modiolus was identified, 2 different 2–0 polypropylene sutures were passed from the oral commissure modiolus and an area of nasolabial sulcus near the nasal base. Those sutures and tissues were suspended and finally fixed to a hole that was drilled through zygomatic bone arch (Fig. 2). Preoperative and postoperative photographs were evaluated, and alar base levels and angulations were measured and compared. A Kolmogorov-Smirnov test was used to evaluate the distribution of variables, and a 2-paired sample t-test was used for the NOSE scale comparison. The NOSE scales were presented as the mean standard deviation; a P-value
