The external rhinoplasty approach for congenital nasal lesions in children

Rhinoplasty Surgical Technique for Nasal Dermoid Cyst Removal in Adult: Case Report

Nasal dermoid cyst is a rare benign lesion. The mainstay of treatment for a nasal dermoid cyst is surgical excision, which aims to remove the cyst and associated structures to prevent recurrence. We report a case of a 30-year-old man with nasal dermoid cyst, without intranasal or intracranial extension. The patient underwent open rhinoplasty technique for dermoid cyst excision. He had an uneventful postoperative recovery and was discharged well. The cyst and associated structure were successfully removed. There was no evidence of recurrence and complications postoperatively after 2 years of follow-up.

Post dermoid excision nasal tip deformity correction using gelatin sponge

Reconstruction of the nasal tip after the excision of the dermoid cyst is difficult, especially if the size of the dermoid is large. Tip reconstruction using Interdomal sutures of alar cartilages and auricular cartilage graft has been used in such cases. We share a new method to manage the nasal tip defect following excision of nasal dermoid, using an absorbable gelatin sponge. A 13 years old female presented with a swelling tip of the nose for the past 2 years. The CT scan revealed a dermoid cyst at the tip of the nose over the alar cartilage with prominent buckling of the cartilages. The Dermoid cyst was excised through an open rhinoplasty incision. There was a defect of 2.2 cm diameter at the tip of the nose with deformed alar cartilages. A piece of absorbable gelatin sponge was folded, cut according to the shape of the cavity, and used to fill the cavity. The skin was draped over the cartilage and gelatin sponge. The post-operative period was uneventful. After 2 years of follow-up, the patient remained asymptomatic and satisfied with a nice contour of the nasal tip.

Nasal Obstruction in the Infant

Neonatal nasal obstruction is common in both the hospital and clinic settings. Causes can range from rhinitis to congenital masses, with a wide variety of congenital nasal masses described. A complete history and physical examination are necessary for correct diagnosis and management. Arhinia and bilateral choanal atresia will present with complete obstruction leading to forced mouth breathing. Partial obstruction will require assessment of nasal patency with possible nasal endoscopy and imaging. Medical and surgical options for treatment are discussed.

Comparing plastic surgery and otolaryngology surgical outcomes and cartilage graft preferences in pediatric rhinoplasty: A retrospective cohort study analyzing 1839 patients

ABSTRACT

Rhinoplasty in children has raised concerns about its safety in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. We analyzed post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists.Data was collected through the Pediatric National Surgical Improvement Program from 2012 to 2017. Current Procedure Terminology codes were used for data extraction. Patients were grouped according to type of rhinoplasty procedures (primary, secondary, and cleft rhinoplasty). A comparison between plastic surgeons and otolaryngologists was made in each group in terms of postoperative complications. Additionally, a sub-group analysis based on cartilage graft preferences was performed.During the study period, a total of 1839 patients underwent rhinoplasty procedures; plastic surgeons performed 1438 (78.2%) cases and otolaryngologists performed 401 (21.8%) cases. After analyzing each group, no significant differences were noted in terms of wound dehiscence, surgical site infection, readmission, or reoperation. Subgroup analysis revealed that plastic surgeons prefer using rib and ear cartilage, while otolaryngologists prefer septal and ear cartilage.The analysis of 1839 pediatric patients undergoing three types of rhinoplasty procedures showed similar postoperative outcomes, but different cartilage graft utilization between plastic surgeons and otolaryngologists.

Nasal dorsum reconstruction after pediatric nasal dermoid excision

BACKGROUND

To review our experience with pediatric nasal dermoids, and discuss reconstructive options for the nasal dorsum after pediatric nasal dermoid removal.

METHODS

Retrospective review of pediatric nasal dermoid cases from January 1 2005 through October 1 2016.

RESULTS

Twenty-five cases (12 males, 13 females) were identified. Median age at time of surgery was 24 months (7-144). Ten nasal dermoids were superficial; eleven, intraosseous; one, intracranial extradural; three, intracranial intradural. Seven were located on the glabella; fifteen, dorsum; three, nasal tip. Twelve underwent vertical midline incision; ten underwent external rhinoplasty; and three combined approach with craniotomy. There was one recurrence four years postoperatively; which was secondarily resected completely via external rhinoplasty approach. Seven cases utilized endoscopic assistance. Conchal cartilage grafting was utilized in nine cases for dorsal reconstruction. A temporoparietal fascial graft was utilized to reconstruct the soft tissue defect in three patients. Median follow-up was 1.17 years (1 month-10 years).

CONCLUSIONS

Nasal dermoid is a rare congenital pathology. Recurrence rate is generally low provided that complete surgical excision is achieved. Achieving complete surgical excision means sometimes compromising the upper lateral cartilages and nasal bones. Conchal cartilage grafting is useful in reconstruction for lesions that significantly disrupt the nasal cartilages and/or nasal bones, wherein the defect is significant and osteotomies may not be sufficient. Temporoparietal fascia is a favorable adjunct for reconstructing soft tissue deficits when the skin is thin. Further studies and longer follow up are needed to adequately assess functional and cosmetic outcomes.

Pediatric nasal dermoid- a decade's experience from a South Indian tertiary care centre

INTRODUCTION

Nasal dermoid sinus cyst (NDSC) are uncommon congenital lesions in children.

OBJECTIVE

To review the clinical and radiological presentation and study the surgical outcomes of this uncommon lesion.

METHOD

Retrospective chart review of all children diagnosed with nasal dermoid from 2010 to 2020 at a tertiary referral hospital in South India was executed. The medical records were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes and literature review was performed.

RESULT

A total of 25 children [Mean age 3.7 yrs (Range 2-9 yrs)] with nasal dermoid sinus cysts were treated in the last decade. While 13 presented with a sinus, 11 presented with cyst and 1 had both. The lesions mainly involved the upper third of the nose in 10 children, middle one third in 6 and upper one third in 9 children. All underwent Magnetic Resonance Imaging, in 11 Computed Tomography also was done. A flow chart of the lesion characteristics and its management has been presented. Intraoperatively intracranial extension was present in four children. The approach to intracranial extension and corresponding literature review has been presented. Follow up ranged from one to six years. (Median 3.5 yrs) and no recurrence or complication was noted.

CONCLUSION

Nasal dermoid is an uncommon congenital anomaly. Preoperative evaluation must include imaging to assess extent and rule out intracranial extension. Surgical strategy depends on whether presentation is as sinus or cyst and location and extent of lesion. All surgical approaches have a good surgical and cosmetic outcome.

Combined minimally invasive surgical management of a nasal dermoid sinus cyst affecting the frontal sinus: literature review and new classification

Introduction

Nasal dermoid sinus cysts (NDSCs) are the most common lesions associated with midline craniofacial anomalies, in the majority of cases diagnosed during childhood. NDSCs affecting the frontal sinus are rare.

Aim

To demonstrate the clinical, radiological and diagnostic pitfalls of NDSCs affecting the frontal sinus.

Material and methods

A retrospective analysis of NDSCs affecting the frontal sinus with a literature review and a novel classification is presented.

Results

We present a rare and complex case of an NDSC in an adult patient that affected the frontal sinus. Endoscopic-assisted open rhinoplasty with endoscopic sinus surgery – Draf type 2B approach – was performed as an effective removal method of choice. A literature review supports our report.

Conclusions

NDSCs affecting the frontal sinus can mimic complications of sinusitis. A minimally invasive combined technique of endoscopic-assisted open rhinoplasty with endoscopic sinus surgery – Draf type 2B frontal sinus approach – is recommended for treatment.

Intracranial Nasal Dermoid Sinus Cyst: Transnasal Endoscopic Resection by Open Rhinoplasty Approach, With Intraoperative Video

Nasal dermoid sinus cysts are rare congenital lesions that may lead to recurrent soft tissue infections and severe intracranial complications. In case of an intracranial extension, the traditional surgical approach includes a frontal craniotomy with significant morbidity. As a less invasive alternative, a transnasal endoscopic approach has been recommended.This report describes the transnasal endoscopic resection of an intracranial nasal dermoid sinus cyst via an open rhinoplasty approach, which achieved a wide surgical exposure with minimal invasivity and ideal aesthetic results. An intraoperative video demonstrates this combination of techniques in this rare skull base/intracranial pathology.

Management of midline nasal dermoid lesions in children by external rhinoplasty

Objectives

Nasal dermoid cysts are rare congenital lesions of ectodermal and mesodermal origin. Treatment of these cysts entails complete surgical excision, and several surgical incisions have been advocated. We present our experience utilizing an external rhinoplasty approach in seven children with nasal dermoid cysts and fistulae.

Methods

A prospective study of 7 cases of nasal dermoid cysts and sinuses, diagnosed clinically and radiologically, were successfully treated by an external rhinoplasty approach in two teaching hospitals during the period of Apr 2011 to Nov 2013. Post operatively, an average follow-up of 12 months was observed by clinical examination, and the outcomes were documented and analysed.

Results

Seven children, 5 girls (71%) and 2 boys (29%), with ages ranging from 1.5 years to 16 years, who had nasal dermoid cysts and/or sinuses were successfully excised via an external rhinoplasty approach. The clinical presentation included midline facial swelling in five patients, a midline sinus in one patient and a dorsal midline nasal pit in one patient. No accessory tracts were found in these seven cases. Complete excision was achieved in 6 patients. There was one recurrence after 6 months with a successful complete resection with revision external rhinoplasty. All patients were followed up for an average of one year post operatively.

Conclusion

The external rhinoplasty approach is an effective surgical approach in treating paediatric nasal dermoid cysts and sinuses with a very low incidence of recurrence.

Pediatric rhinoplasty: A discussion of perioperative considerations and systematic review

OBJECTIVES

Pediatric rhinoplasty has traditionally raised numerous concerns, including its impact on growth as well as the psychological sequelae of undergoing a potentially appearance-altering procedure. Our objective was to critically evaluate available individual patient data relevant to pediatric rhinoplasty, and further discuss perioperative considerations.

METHODS

A systematic review was conducted using PubMed/MEDLINE databases. Data extracted and analyzed from included studies included patient demographics, surgical indications, operative approaches, outcomes, complications, revision rates, and other clinical considerations.

RESULTS

Seven studies encompassing 253 patients were included, with age ranging from 7 months to 19 years. Two-thirds of patients were male. 41.7% reported antecedent trauma, and common overall surgical indications included "functional aesthetic" (24.5%) followed by cleft lip nasal deformity (15.8%). The majority (79.1%) underwent open approaches, and 71.1% of patients underwent concomitant septal intervention. The most frequently used grafting materials were septal cartilage (52.8%) and conchal cartilage (16.5%). Surgical outcomes were heterogeneous among these studies. Complication rates were only specified in 5 of the 7 studies and totaled 57 patients (39.6%). Aesthetic dissatisfaction (11.8%) and postoperative nasal obstruction (5.6%) were the most commonly reported complications. Revisions were performed in 13.5%.

CONCLUSION

Rhinoplasty is safe in the pediatric population, although revisions rates appear greater than those reported in adults. This study of 253 represents the largest pooled sample size to date; nonetheless, non-standardized outcome measures, minimal long-term followup data, and lack of discussion regarding psychological sequelae all contribute to the need for further high-quality studies evaluating this topic.

Excision and Fat Grafting of Nasal Tip Dermoid Cysts Through an Open Rhinoplasty Approach

Nasal tip dermoid cysts that are present in pediatric patients can be complicated by mass effect causing compression and distortion of underlying cartilaginous structures. The purpose of this report is to describe a single surgeon's technique and results of nasal tip dermoid cyst excision in pediatric patients through an open rhinoplasty approach followed by tip reconstruction and immediate fat grafting. A series of 3 pediatric patients presented with 1 to 1.5 cm nasal tip dermoid cysts that were causing distortion of the lower lateral cartilages. All 3 underwent excision of the cyst through an open rhinoplasty approach. The nasal tip was reconstructed with interdomal sutures and immediate fat grafting. Fat grafts were harvested from the abdominal wall and implanted in the nasal tip. The grafts filled the resulting dead space and were secured with the fibrin glue. The soft tissue was redraped, and the skin was closed. The final postoperative result, 2 years after surgical intervention, included a well-proportioned and appropriately shaped nasal tip without obvious incisional scars in all patients. The skin overlying the previously excised dermoid cyst was supple and healthy. Excision of nasal tip dermoid cysts in pediatric patients can be approached through an open rhinoplasty approach, tip reconstruction, and immediate fat grafting. This approach can provide assistance in correcting contour deformities and may help preserve an at-risk soft-tissue envelope.

Disorders of the neonatal nasal cavity: Fundamentals for practice

Neonatal nasal obstruction is a well-known clinical entity. Fortunately, it is rarely life-threatening and usually resolves with conservative management. As with most conditions, a systematic history and thorough physical examination are crucial for correct diagnosis and management. The initial diagnosis may be elusive and require either serial or more in-depth evaluations. Occasionally, examination may reveal structural abnormalities necessitating surgical intervention. Fortunately most of these abnormalities are amenable to surgery; however, a select few are notoriously difficult to treat.

Midline nasofrontal dermoids in children: A review of 29 cases managed at Mansoura University Hospitals

OBJECTIVES

Nasal dermoids are congenital anomalies constituting 3.7-12.6% of dermoids in the head and neck. Most of lesions are superficial but there is always a risk that it may end blindly within the deep structures of the nose or extend intracranially. Complete excision, regardless of extension, is essential and must be balanced against cosmoses. This study reviews the clinical characteristics and imaging findings as well as the appropriate surgical approach adopted for 29 cases managed at Mansoura University Hospitals.

METHODS

A retrospective analysis was performed in 29 patients admitted for management of nasal dermoid between Jan 2001 and Jan 2015 at the Otolaryngology department of our tertiary referral university hospital. Recorded data included patient's demographics, complaint, lesion's site, pre-operative radiological findings, surgical technique, intra-operative findings, and post-operative squeal.

RESULTS

This series included 12 (41%) female and 17 (59%) male children, with a mean age of 2.5 years. Twenty seven children presented with a nasofrontal swelling of which 20 had an apparent sinus. Other presentations included a swelling in the inner canthum (1), nasal tip and columella (1). Nine (31%) patients had a history of infection and two patients gave a positive history of meningitis. Intracranial extradural extension was identified in 10 patients (34.5%) during preoperative imaging. Surgical modalities included local excision and direct closure (12), open rhinoplasty (7), bicoronal excision and craniotomy (10). In 9 cases, the tract was adherent to the dura but was carefully dissected and in one case resection required excision of a segment of dura and reconstruction. In a follow up period of 1-8 years, recurrence was detected in one case and the cosmetic results were satisfactory.

CONCLUSIONS

Those lesions are rare and require early precise surgical planning to achieve complete en bloc excision. This study reports a low morbidity associated with management of nasal dermoids with intracranial extension.

[A nasal congenital malformation not published in the literature: About 5 cases]

AIM OF STUDY

Five cases of the same congenital malformation of the nose, affecting the nasal dorsum and the supra-tip, were supported in our university plastic surgery center. This malformation has not been described in the literature known to the authors. The aim of this study is to analyze this nasal deformity.

PATIENTS AND METHODS

Five children presented this congenital deformity between 1994 and 2014. The patients were examined and the malformation precisely described. Genetic and histological examinations were carried on. The diagnosis and treatment of this pathology were discussed.

RESULTS

This malformation associated 4 anomalies: hypertrophy of soft tissue of the dorsum located in the middle third of the nasal bridge, deformed alar cartilages turned back downward and outside, advanced support default and median skin brand similar to a scar. These patients showed no other abnormalities of the midline or respiratory disorders. No genetic disorder was found for these five patients, and no histological arguments were found. Three patients were operated, one until adulthood with a satisfying cosmetic result.

CONCLUSION

Bibliographic research has not allowed us to make an accurate diagnosis of this malformation that appears to be non-syndromic and to have a genetic origin. Our therapeutic approach became more clear and it now seems legitimate to propose early excision of fat mass to prevent alar deformations, associated with a cortico-cancellous graft, which in our experience grows with age, to support the tip.

Update on current evaluation and management of pediatric nasal dermoid

OBJECTIVES/HYPOTHESIS

To review the presentation of congenital pediatric nasal dermoid and present guidelines for its evaluation and management.

STUDY DESIGN

Retrospective chart review from 1970 to 2014 at a tertiary referral children's hospital.

METHODS

The medical records of all patients diagnosed with a nasal dermoid during the study period were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes.

RESULTS

Ninety-six patients underwent excision of a congenital nasal dermoid during the study period. The mean age at presentation was 3.1 years (range, 0.1-19.3 years). Thirty-four (35%) females and 62 (65%) males were included. The most common presentation was a nasal dorsal mass in 66 (69%) patients. Ninety-two (96%) of the patients underwent preoperative imaging. Seventy-eight (82%) of the patients did not show any clinical or radiographic evidence of intracranial extension preoperatively. Eighty-five (89%) of the patients underwent extracranial excision, and 11 (11%) underwent combined intracranial and extracranial excision. Eight patients (8%) presented with recurrence, on average 3.3 years (range, 1-6 years) after initial excision. Mean follow-up time was 8 years (range, 1-18 years).

CONCLUSION

Preoperative imaging of nasal dermoid is crucial to evaluate for intracranial extension, thus facilitating complete removal. Thin section, high-resolution magnetic resonance with contrast provides excellent detail of the extent of the nasal dermoid including intracranial extension. Thin-section high-resolution computed tomography with multiplanar reformatted images provides complimentary information regarding the bone anatomy of the frontonasal region. Surgical strategy is dictated by preoperative imaging and is dependent on the extent of the lesion, but limited facial incisions are preferred.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2151-2160, 2016.

The management of midline frontonasal dermoids: a review of 55 cases at a tertiary referral center and a protocol for treatment

BACKGROUND

The incidence of midline frontonasal dermoid cysts is one in 20,000 to one in 40,000. These lesions may have intracranial extension. This is explained by the anatomy and embryology of nasofrontal development. Skin involvement may also be extensive. Incomplete excision frequently leads to recurrence. The authors report their experience and pathway for management of midline dermoids.

METHODS

Databases were searched to identify patients who had undergone surgery for removal of a dermoid cyst. Preoperative imaging and indications for surgery were reviewed. Cases were grouped according to surgical approach, and outcomes and complications were identified.

RESULTS

Fifty-five patients were treated. Magnetic resonance imaging or computed tomography was used to delineate the anatomy, and surgical excision was expedited if there was a history of infection, especially if imaging suggested intracranial extension. Twelve patients were treated endoscopically (one was converted to open). Eleven required transcranial approaches for intracranial extension (20 percent). Of these, one lesion breached the dura. The remaining 32 patients had dermoids excised with an open approach (direct, bicoronal, or rhinoplasty). There were no recurrences in the open group and there was one recurrence in the transcranial group. This was treated by reexcision.

CONCLUSION

Midline dermoid cysts are relatively uncommon. However, knowledge of the pathogenesis of these lesions together with the authors' experience over 15 years has allowed them to develop a protocol-driven approach, with a low incidence of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Endoscopic removal of a dermoid cyst via scalp incision

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar.

Endonasal endoscopic approach for intracranial nasal dermoid sinus cysts in children

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. The frequency of intracranial extensions varies from 5% to 45%. Complete surgical excision of nasal dermoid cyst and any associated sinus tract is essential for cure and any residual ectodermal elements result in a high rate of recurrence and complicated infections. Many different approaches have been described for the removal of nasal dermoids in the past two decades, ranging from a simple extracranial excision to complex procedures in which a combined extracranial-intracranial approach is required. We hereby report two cases of nasal dermoid sinus cysts in children with intracranial extension which were managed with an endonasal endoscopic procedure. We describe the technique we implemented for this procedure and for the reconstruction of the skull base defect.

Endoscopic endonasal surgery for nasal dermoids

Midline congenital lesions are rare and commonly comprise nasal dermoids (NDs), encephaloceles, and gliomas. This article discusses the epidemiology of NDs. Management is also discussed, as well as prognosis.