Postoperative follow-up of juvenile nasopharyngeal angiofibromas: assessment by CT scan and MR imaging

The purpose of this study was to assess the radiological findings after surgical removal of juvenile nasopharyngeal angiofibromas (JNA). The postoperative CT and MRI scans of ten patients were reviewed. The cured group included six patients. The non-controlled group included six patients with eight recurrences. Two patients belonged to both groups as they were also followed and cured after surgery for relapse. Four recurrences were asymptomatic and diagnosed by imaging. The imaging patterns were matched to the patients clinical status and endoscopic findings. In the cured group, non-enhanced residual soft tissue masses were seen in all cases. In the non-controlled group, recurrence was always demonstrated on early postoperative CT or MR as a dramatically enhanced mass. The recurrence was located in the lateral or superior aspect of the nasopharynx (n = 3), deep to the fossa of Rosenmuller (n = 4) or out of the nasopharynx (n = 1). In two cases a remaining enhanced mass disappeared spontaneously on iterated examinations. Because of numerous asymptomatic relapses, a radiological workup is recommended four months after surgery, even in patients with normal endoscopy, to rule out posterolateral or extranasopharyngeal recurrences. Spontaneous evolution of residual masses must be appreciated on iterated imaging examinations.

[Hypoglossal-facial anastomosis. A report of 60 cases]

The authors report their experience of 60 cases of hypoglosso-facial anastomosis. The results of this retrospective series were analysed by the same examiner according to the House and Brackmann classification. The surgical technique is rapidly described, with emphasis on the important points. The results are analysed as a function of the interval between the anastomosis and facial paralysis: better and more rapid results are obtained when surgery is performed early (80% of grade 3 with immediate surgery versus 50% in very late surgery after more than 4 years). However, grade 3 or 4 can be obtained in every case, even in the case of very late surgery. Other favourable prognostic factors were revealed by this study: specialized rehabilitation and especially the patient's psychological must be integrated in this nerve transfer. In view of these good results and the limited adverse effects (atrophy of the hemi-tongue, eye-mouth synkinesias), hypoglosso-facial anastomosis must be part of the therapeutic strategy of total, permanent facial paralysis.

Objective evaluation of dysphonia: preliminary results of a device allowing simultaneous acoustic and aerodynamic measurements

Voice quality analysis was performed in 88 normal speakers and 157 dysphonic speakers using a device that allows simultaneous study of acoustic and aerodynamic parameters during pronunciation of a sustained /a/. We compared the results with those of voice quality grading by a jury. The Mann-Whitney test showed significant differences between the grades of dysphonia for all the parameters chosen. Comparison of results (using discriminant factorial analysis) with perceptual evaluation by a jury showed concordance in 66.1%. Based on these preliminary results, the authors conclude that their protocol overlooks some relevant voice parameters like middle-term variations. Further study will be undertaken to take into account this type of variations.

Role of magnetic resonance imaging in predicting late facial motor function after removal of vestibular schwannomas by the translabyrinthine approach

Facial motor function was assessed in 61 patients 18 months after surgical resection, by the translabyrinthine approach, of vestibular schwannoma involving both the cerebellopontine angle (CPA) and the auditory canal. Pre-operative magnetic resonance imaging (MRI) was performed to measure the maximum extracanalicular diameter of the tumour between the porus and the farthest extension in the CPA on transverse slices and to calculate extracanalicular tumour volume. Post-operative facial motor function was graded according to the House and Brackmann system. There was a statistically significant relationship between late facial motor function and extracanalicular diameter. The best cut-off point for good and poor results was 20mm. There was no relationship between the tumour volume and the late post-operative facial motor function grade. In this study the best pre-operative radiological predictor of the late facial motor function in patients operated on by the translabyrinthine approach was the maximum diameter measured by MRI.

Juvenile nasopharyngeal angiofibroma: comparison of blood loss during removal in embolized group versus nonembolized group

PURPOSE

This retrospective study was performed to assess the beneficial effect of preoperative embolization of juvenile nasopharyngeal angiofibromas (JNA) in terms of blood loss during surgery.

METHODS

Intraoperative blood loss in a group of 7 patients who underwent 10 procedures for JNA without preoperative embolization was compared with the blood loss of 13 patients who underwent 16 procedures after embolization of one or both external carotid arteries.

RESULTS

Mean blood loss was 5380 ml in patients without embolization and 1037.5 ml in those with embolization. This difference was not statistically significant because of the high standard deviation in the nonembolized group. However, when data were analyzed by tumor stage, a significant difference was noted between the embolized and the nonembolized patients with high-grade tumors but not between those with low-grade tumors.

CONCLUSION

Preoperative embolization of the branches of the external carotid appears to facilitate removal of high grade tumors. The benefit of embolization in those with low-grade tumors is less clear cut, probably because there is less vascularity in low-grade tumors and so removal is easier.

Protrusion of the optic nerve into the ethmoid and sphenoid sinus: prospective study of 150 CT studies

Damage to the optic nerve is a serious complication of intranasal sinus surgery. Protrusion of the optic canal into the sphenoid sinus is a major risk factor. In this prospective study of 150 CT studies, we found this anatomical variation in 8% of cases. It was consistently associated with pneumatisation of the ipsilateral anterior or clinoid process. Protrusion of the optic nerve into the posterior ethmoid cells was never observed. CT is a useful part of the preoperative investigation of patients undergoing intranasal sinus surgery. Axial and coronal images obtained or by direct acquisition by reconstructions are necessary to show the position of the optic nerve.

Effect of heavy smoking on nasal resistance

Smoking is a part of our sociocultural environment. Its medical consequences are probably still underestimated. In this prospective clinical study, we explored the relationship between heavy smoking and nasal resistance. Anterior rhinomanometry was performed in 26 smokers and 26 non-smokers. Each group contained 13 men and 13 women. Analysis of variance of nasal resistance measurements using age and weight as covariables showed no significant difference between sexes. In contrast, a highly significant increase was noted between smokers and non-smokers. Age and weight had no influence on these results. Rhinomanometry proved to be an excellent method of detection for these modifications. Similar studies on the effects of passive smoking and of atmospheric and occupational pollutants should follow in the near future.

[Intra-sphenoidal prolapse of the internal carotid artery. Computed tomography of 300 sinuses]

OBJECTIVES

Endonasal sphenoidotomy is a high risk operation: fatal complications due to direct lesion to the internal carotid artery have been reported. We conducted a prospective analysis of carotid prolapse within the sphenoid cavity in order to draw attention to this dangerous anatomic variant.

METHODS

Tomodensitometry of the sinuses was performed in 150 patients (mean age 35 years; range 20-70) with inflammatory nasal symptoms of less than one year duration (mean 5.2 months). Cases with benign or malignant tumours, polyposis or a past history of sinus trauma were excluded. Transversal sections were analyzed by one radiologist and one ear-nose-throat specialist. The diagnosis of carotid prolapse was defined as an intrasphenoid protrusion of the artery at least as long as one-third of its circumference. Results of the analysis were expressed as percent for 300 sinuses.

RESULTS

Prolapse of the internal carotid was found in 20.3% of the sinuses (n = 61). In all cases a thin (> 1 mm) bony structure surrounded the artery. No prolapse was observed into the posterior ethmoid cells.

CONCLUSIONS

Intrasphenoid prolapse of the internal carotid artery is a major risk factor in nasal and sinus surgery. The high incidence (1 out of 5 sinuses) indicates the need for routine preoperative imagery to reduce surgical risk.

Difference in the height of the right and left ethmoidal roofs: a possible risk factor for ethmoidal surgery. Prospective study of 150 CT scans

A prospective study of 150 CT scans showed that the right ethmoidal roof was lower than the left in 8.6 per cent of cases. The reverse situation, i.e. the right higher than the left, was observed in only 1.2 per cent of cases. This finding could account for the higher reported incidence of endocranial complications associated with right ethmoidectomy. Coronal CT scans allowing comparison of the right and left ethmoidal roofs should always be made before undertaking intranasal ethmoidectomy.

Major complications of sinus surgery: a review of 1192 procedures

Based on this review of 1192 intranasal sinus procedures under endoscopic control with video assistance, the risk of major complications was estimated to be about 1.3 per cent. Ethmoidectomy was the most hazardous procedure. Operation by a right-handed surgeon standing on the right side of the patient was an added risk factor. We stress ways of achieving prevention, peroperative recognition of cerebrospinal fluid leaks and proper management of complications.

[Surgical approach of the petrous vertical segment and upper cervical internal carotid]

The main obstacle to successful management of aneurysms involving the high cervical internal carotid artery (ICA) is to obtain an adequate exposure. In this report we describe our experience in 5 patients presenting carotid aneurysms at the skull base, intermediately below the carotid foramen. Exposure is achieved in two stages. The cervical stage consists in resection of the styloid processes and muscles followed by anterior displacement of the mandibular condyle. This exposes the vertical segment of the petrous ICA. The petrous stage consists in partial petrectomy exposing the jugular bulb and the third segment of the facial nerve. Using this route, the vertical intrapetrous segment of the ICA can be drilled away without damaging the middle ear. In our series, no vascular complications occurred. Damage involving the facial glossopharyngeal and vagal nerves is discussed. This approach appears to be a suitable alternative to the conventional infratemporal approach which sacrifices the middle ear.

Near total laryngectomy with epiglottic reconstruction: long-term results in 57 patients

INTRODUCTION

Extended partial laryngectomy procedures may offer patients the potential for a cure with preservation of voice. This report characterizes our patients managed with near laryngectomy and reconstructed with epiglottic tissue.

MATERIALS AND METHODS

A total of 57 patients with T1 or T2 glottic carcinoma undergoing total laryngectomy with epiglottic reconstruction were reviewed retrospectively. This group included 15 patients with T1 lesions and 42 patients with T2 lesions. In the standard operation the specimen includes the thyroid ala, both vocal cords, both false vocal cords, and one arytenoid cartilage. The epiglottis is mobilized and delivered inferiorly for reconstruction of the glottic larynx.

RESULT

Tumor control was obtained in 93% of T1 patients and 79% of T2 patients. All patients tolerated decannulation. After a mean duration of 12 days (range 5 to 22 days), all patients were able to swallow. Voice evaluation revealed 5 patients had whispery voices, 25 were difficult to understand in a noisy environment, and 27 were easily understood.

DISCUSSION

This technique is an effective approach to cancer therapy with cure rates comparable to total laryngectomy. The main limitation of this technique is that voice recovery is unpredictable.

[Rhinosinusal manifestations of cystic fibrosis]

The generalized disorders which characterize cystic fibrosis often involve the nose and paranasal sinuses and may frequently lead to the development of nasal polyps. A retrospective study of 78 patients with cystic fibrosis, 3 to 28 years old, was undertaken in order to determine the incidence of nasal involvement and to define an approach to the treatment of disabling recurrent nasal polyposis. 65% of these patients presented chronic symptoms such as rhinorrhea, nasal obstruction and disturbances of smell. Nasal polyps were found in 50% of patients and were more frequent in adults than in children. Clinical symptoms were directly related to the extent of polyp development which could be classified according to 3 groups. CT scans showed maxillary sinus involvement in almost all patients. The incidence and extent of ethmoidal sinus involvement on CT scans was correlated to the grade of polyp development. Medical treatment of polyposis failed in all cases. Polypectomy was always followed by recurrence. Intranasal ethmoidectomy seems to be an interesting alternative, since 73% of patients undergoing this procedure had clinical improvement.

[Deafness caused by malformation of the inner ear. Current contribution of x-ray computed tomography]

Hearing loss due to malformations of the auditory system may involve morphologic abnormalities of the external canal, the middle ear, or the inner ear. Various combined malformations are possible. Audiologic assessment and computed tomography make it possible to perform a precise diagnostic evaluation of inner ear malformations. In a series of 71 children with congenital sensorineural hearing loss, 31 had computed tomographic evidence of malformations. Since 19 children had bilateral lesions, a total of 50 ears were studied. The cochleovestibular abnormalities were typed and correlated to the severity and progression of hearing impairment. The 3 most frequently encountered malformations were: 1) isolated large cochlear aqueduct (n = 12), 2) large vestibular aqueduct (n = 8) and 3) the Mondini malformation (n = 7). The most severe hearing losses were associated with cochlear hypoplasia and incomplete cochlear segmentation. The severity of hearing impairment decreased with the following abnormalities in the order given: 1) large cochlear aqueduct, 2) Mondini malformation and 3) large vestibular aqueduct. Among the 15 patients with progressive hearing loss, 13 had large cochlear aqueducts either isolated or concomitant with other lesions. While certain evident abnormalities, such as cochlear aplasia or Mondini malformation, are relatively easy to diagnose, other more subtle morphologic changes, such as large cochlear aqueduct, still need to be better defined according to precise criteria for radiographic evaluation.

Hydroxyapatite in experimental laryngotracheal reconstruction

Current concepts in laryngotracheal reconstruction include lumen augmentation with interposition of autogenous costal cartilage. In an effort to reduce potential increased morbidity at the donor site, the use of porous hydroxyapatite was compared with autogenous costal cartilage in an experimental study. Ninety-nine New Zealand rabbits were randomly operated on to receive autogenous costal cartilage (n = 32), hydroxyapatite covered by a perichondrium graft (n = 33), or hydroxyapatite alone (n = 34). Rabbits were killed at 3 months after the surgery. Clinically (n = 85), no difference was found among the groups. Histologically (n = 81), grafts (n = 54) in the group receiving autogenous costal cartilage were greater than in those receiving the hydroxyapatite. Concerning the value of epithelial layer covering the graft, the rate of inflammation, the cricoid-graft interface, and the graft viability, no difference was noted among the groups. In the group in which no graft was found (n = 27), a fibrous bridge maintaining a cricoid distraction was noted in 23 cases. This study shows the possible value of hydroxyapatite in the animal model, but before clinical application, the natural course of the fibrous bridge must be documented.

Traumatic aneurysms of the internal carotid artery at the base of the skull. Two cases treated surgically

Internal carotid aneurysms at the base of the skull after blunt trauma are infrequent but their management is difficult, leading many surgeons to only attempt ligation. We report 2 cases presenting with high traumatic aneurysms, following motorcycle accidents. The 2 aneurysms underwent repair by a venous graft. The petrous portion of the carotid artery was approached and controlled by an ENT surgeon. This "infratemporal" approach was used exposing the facial nerve, combined with temporary anterior sub-luxation of the temporomaxillary joint to expose the lower part of the carotid canal which was opened up with a drill in order to control the carotid artery in the petrous canal. Both patients developed facial nerve palsies which improved within 3 months. Postoperative angiography showed patent vein grafts and the patients were doing well, without any symptoms 18 and 24 months later.

Intranasal ethmoidectomy in nasal polyposis in children. Indications and results

Nasal polyposis in children is a rare pathology that is difficult to treat, with results that are often disappointing. The aim of this paper is focused on the surgical possibilities of ethmoidectomy by endonasal approach. Thirty-nine ethmoidectomies were performed in 24 children with a mean age of 12 years (cystic fibrosis, n = 7; Woakes' syndrome, n = 2; isolated polyposis, n = 15). The decision for surgical treatment was based upon the severity of initial symptoms, principally nasal obstruction, lack of improvement after medical treatment, and the assurance of good surgical follow-up. Twenty-three children were followed up for a mean of 3 years. Complete recurrence was noted in 13% of the cases (n = 3). In all the other cases, including those with partial recurrence, the lives of the children were transformed. Ethmoidectomy by endonasal approach is reliable if the appropriate surgical techniques are strictly followed. It has proven its efficacy in children with nasal polyposis with results that are very encouraging compared to previously proposed therapies.

[How to evaluate velar insufficiency?]

The evaluation of velar insufficiency is absolutely necessary in order to assess the results of surgery of the labial palatal cleft. In addition to the clinical examination which remains indispensable, the aerophonometer, applicable to adults and children as from the age of 3, enables simultaneous measurement of the flow of buccal air, the flow of nasal air, and the buccal phonogram. The comparison of the lines, the relation of the nasal air and buccal air flows, upon the emission of two standard sentences with and without nasal components, enables an objective assessment of velar functioning.

[Repair of the auricular area after petrosectomy]

The authors report a retrospective series of 12 patients presenting periauricular tumors having invaded the external auditory canal and concha: 5 squamous cell carcinomas, 3 basal cell carcinomas, 2 Darrier-Ferrand sarcomas, 1 parotidean adenocarcinoma, 1 radionecrosis. The operation included an extralabyrinthic petrosectomy, an amputation of the pavilion, and a ganglionic evidement following a histological analysis. The reconstruction processes used 3 pedicle grafts and 9 free grafts. The carcinological extension modalities of the cancers invading the entire external auditory canal require the sacrifice of the tympanic cavity and an external temporalectomy in a single block for carcinological and functional reasons. The massive invasion of the concha inevitably leads to the sacrifice of the auricular pavilion. The best means of reconstruction is with the free graft of the musculus latissimus dorsi. The price to be pay esthetically must be reduced by the placement of an epithesis.

Subglottic cyst in a newborn

Subglottic laryngeal cysts in the newborn are extremely rare. It is difficult to establish if the cyst is acquired or congenital because respiratory distress requires intubation in the I.C.U. generally without prior endoscopy. A case report is presented, followed by a discussion of possible aetiology and management protocol; the advantages of the CO2 laser make excision of the cystic sac possible without tracheotomy.

Septorhinoplasty in children: benefits of the external approach

Following a series of septorhinoplasties performed on 28 children over a period of eight years as well as a review of the literature, the authors consider that the taboo on this sort of surgery would seem to have passed. Given that the septum plays a fundamental role in the projection of the nasomaxilliary complex, it is clear that certain surgical rules must be applied: the perichondrium must be left intact, no wide cartilaginous resections must be made, the areas of contact between the septum, the vomer, and the perpendicular lamina of the ethmoid must be reconstituted, and finally, the remodeled cartilage must be repositioned. For all of the above reasons, the external approach, performed on 20 children, is the best suited for this sort of operation. No serious long-term complications were observed.

Experiences at the Timone Hospital, Marseille in acoustic neuroma surgery

The authors report their experiences after operating on 279 patients with unilateral acoustic neuromas between 1976 and 1988, with 258 cases managed by the translabyrinthine approach and 21 cases by the middle fossa approach. The authors emphasize the necessity for total removal in order to avoid recurrences.

The widened transcochlear approach to jugular foramen tumors

The authors describe a widened transcochlear approach for large tumors of the jugular foramen with intrapetrous, intracranial, and infratemporal extensions. This approach complements the transcochlear and infratemporal approaches by enlarging the route of access to the region with disinsertion of the sternocleidomastoid, digastric, and stylohyoid muscles, by removing petrous bone in order to displace the facial nerve, by resection of the auditory canal, and by subluxation of the temporomandibular joint and zygomatic process. The use of this approach is described in seven patients.

[Magnetic resonance imaging in the study of acoustic neurinoma]

Exploration of acoustic neurinoma, the most frequent benign tumor of posterior fossa, now includes magnetic resonance imaging, and an C.G.R. supraconductor apparatus (0.5 Tesla) has been in use since March 1986. This equipment provides high resolution frontal sections, not only of posterior fossa but of the two pontocerebellar angles and even the contents of the two IAC (thin, contiguous 4 mm sections in 256 x 256 matrix). A total of 43 patients were examined, 37 with surgically confirmed acoustic neurinoma and 2 with tumor recurrence. The neurinoma appears on the first echo as a hyposignal in relation to brain stem in sequences predominant in T1 and as a hypersignal in relation to peripontic CSF in sequences predominant in T2. Short sequences predominant in Tl (partial saturation or short ET and RT spin-echos) appear to be most effective for detection of acoustic neurinoma. Comparison of MRI and CT scan imaging showed that firstly, all cases detected by conventional scanography were correctly analyzed by MRI, with superiority for MRI for preoperative screening due to the frontal sections obtained without interference and, secondly, the non-invasive confirmation of diagnosis in doubtful or negative cases requiring computerized gaz meatocisternography. No false negative or false positive results were reported in our series or those documented in the literature using this new imaging technique, but high performance apparatus is necessary (thin sections ans powerful principal magnetic field of at least 0.5 resla). Improvements in this method could be obtained by the availability of more rapid programmes, the use of surface coils and the injection of paramagnetic substances (galodinium chelates) presently under study. NMR imaging is a reliable and non-invasive imaging method capable of replacing the scanner for study of acoustic neurinoma as soon as more apparatuses become available.

[Radiologic diagnosis of acoustic neurinoma. Apropos of 130 patients]

Diagnostic value of radiologic examinations was assessed in a homogeneous series of 130 cases of neurinoma of acoustic nerve seen over the last 10 years. Radiologic exploration is conceived and used at the present time for two purposes. Firstly, it enables selection of patients with suspected acoustic nerve neurinoma. Radiotomography appears to be currently an accessory examination because of the discriminative performance of early auditory evoked potentials tests on the brain stem. Secondly, radiology is necessary for confirmation of diagnosis. Visualization of the tumoral syndrome can be obtained only by a scan or possibly opaque or gas meatocisternography.

[Immunohistochemical detection of calcitonin, ACTH, beta-MSH, beta-endorphin and somatostatin in medullary carcinoma of the thyroid. Immunoperoxidase study (PAP, ABC) of 10 cases]

Ten cases of Medullary carcinoma of Thyroid gland (MCT) were examined (two familial, eight sporadic) in patients with increased serum calcitonin levels and ranging age from 31 to 87 years. Immunocytochemical reactions were performed using Peroxidase-Antiperoxidase (PAP) complex and/or Avidin-Biotin-Peroxidase complex (ABC) by light microscopy on fixed tumorous specimens (10 cases) and additionally by electron microscopy (3 cases). The tumors displayed light microscopic features typical of MCT. The cells were polyhedral, angular or fusiform and showed high affinity for Grimelius stain. Large deposits of amyloid were Congo red stained and disclosed a green birefringence in polarized light. In the familial cases sections of non-tumorous thyroid tissue showed C cell hyperplasia. Electron microscopic studies revealed intracytoplasmic secretory granules and amyloid fibrils. The immunoperoxidase technique demonstrated calcitonin in the tumor cells in all the cases, with a weaker staining than in para-and intra-follicular C cells of adjacent non tumorous tissue and than in C cells hyperplasia foci, when present. Immunoreactive tumor cells were also observed with anti SRIF in 4 cases, with anti-ACTH and anti-beta MSH in 3 cases, and with anti-beta endorphin in 2 cases. These results are discussed with a review of the literature.

[Lateral cervical chemodectoma]

Diagnostic and surgical features of lateral cervical chemodectomas are discussed in relation to a personal series of 13 patients with carotid body tumors and 7 with tumors of the intravagal glomus. Clinically, these affections are poor in symptomatology, those of the carotid glomus presenting as an isolated cervical tumor, intravagal glomus tumors as parapharyngeal masses of the retrostyloid type. Arteriographic findings are discussed in detail, as they constitute the only pathognomonic signs, enable differentiation between the two tumor sites, and supply essential pre-operative data: location of the pedicles, possible invasion of arterial walls, and the limits of the tumor. Surgical approach should be wide to enable control of the distal end of the internal carotid artery, if necessary under the base of the cranium, excision of the tumor usually being possible by employing the subadventitial resection technique.

Calcitonin, somatostatin and ACTH immunoreactive cells in a case of familial bilateral thyroid medullary carcinoma

Bilateral medullary carcinoma of the thyroid (MCT) was discovered in a symptomless patient of a high-risk MCT family. Raised serum calcitonin responding abnormally to pentagastrin led to a thyroidectomy. Grossly, the thyroid showed one nodule in the upper third of each lobe. Light microscopy revealed typical MCT with amyloid deposits. Nontumoral thyroid tissue showed C cell parafollicular hyperplasia. Electron microscopy detected intracellular secretory granules (mean diameter, 150 nm) and typical amyloid fibrills. Immunochemistry revealed numerous calcitonin immunoreactive cells in the nodules, in normal para and intrafollicular C-cells and hyperplastic C-cells. Somatostatin and ACTH were detected in certain tumor cells, but not in normal and hyperplastic C-cells. MCT hormonal production potential is discussed.

[Results of rhinoplasties. A computer study of 351 medical records]

The authors studied the cosmetic results of 1380 rhinoplasties carried out over a period of 10 years by two surgeons, Professor A. Pech and Professor M. Cannoni. They used a classical reduction rhinoplasty technique. Different procedures were used for the tip of the nose depending on the individual indications, and the development of ideas over a period of time. Only 351 files, complete with pre- and post-operative photographs have been selected. The photographs have been analyzed on the basis of 70 criteria by an independent, young female ENT specialist, and the results of her analysis were fed to the computer. The study provides three types of answer. Firstly, the results were good in 69% of cases, and the greater the experience of the surgeon, the greater the success. Secondly, the different techniques for correcting the tip of the nose are analysed with good scores for Cinelli's technique (69%). The tip modeling procedures of Converse and of Lipsett have been abandoned owing to the high frequency of round tips. Finally, the different types of anomalies encountered are listed: 42% round tips, 20% asymmetrical tips, 17% residual humps, 11% of wide nasal bones, hooked noses and postoperative deviations. The authors then comment on the results, focusing on following points: the frequency of incomplete files (70%); the general improvement in the results with the gaining of experience, the decline in the proportion of hooked noses, also in line with experience, from 24% in the first 5 years to 7% after 10 years; the development of ideas concerning the techniques to be used in correcting the tip of the nose with an evergrowing place for those sacrificing the dome of the alar cartilages, such as the "Hockey stick" and a personal procedure derived from Pollot; wide nasal bones and failures in the tracing of the naso-frontal angle (64%) for which no solution is suggested; and, finally, postoperative nasal deviations. Since undertaking this study, the authors have successfully avoided this defect by using the external approach.