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S TA S E : T H T

DISEASE OF THE NOSE, PARANASAL SINUSES,

AND FACE PART 1

MALFORMATIONS OF THE NOSE, PARANASAL SINUSES AND FACE

• Choanal Atresia• Frontobasal Dysraphias• Dorsal nasal fistulas• Dermoids• Cephaloceles

CHOANAL ATRESIA

• Epidemiology1 in 5000 - 10000Unilateral > bilateral• Symptoms- Bilateral

Acutely life threatening emergencyAsphyxia when mouth is closed -> hypoxia -> paradoxical cyanosis, bradycardia, erratic respiratory rate.- Unilateral

Purulent nasal charge on affected side.Possibly accompanied by other anomalies. (CHARGE syndrome: coloboma; heart disease; atresia of the choanae; retarded growth, development and/or central nervous system anomalies; genital hypoplasia; ear anomalies or deafness)

• DiagnosisRigid or flexible endoscope examination

• Treatment- Intubation- Perfortation of atresia plate- Recurrent stenosis -> stent with suture- Definitive surgical repair

- 1week to months for bilateral- School age for unilateral

FRONTOBASAL DYSRAPHIAS

• Epidemiology1 in 20000-40000

• Manifestations- Dorsal nasal fistula

- Keratinized squamous epithelium and forms a tiny opening on the dorsum or tip of the nose.

- Fistulas that terminate blindly manifested clinically at an older age. Inflammation around the fistulous opening

- Fistula tht communicates with the subarachnoid space cause severe complication (cerebrospinal fluid leakage, meningitis, or brain abcess)

• Diagnosis• CT scan• MRI

• Treatment• Complete removal of the fistulous tract.

NASAL DERMOID

• Keratinized squamous epithelium on dorsal nasal midline and nasal flank.• May coexist with a dorsal nasal fistula.• Abcess may develop as an inflammatory

complication.• Treatment: complete removal of fistulous tract.

CEPHALOCELE

• Herniations of intracranial contents through a bony defect in the skull.• Etiology: congenital• Classification: • Sincipital: located near the glabella, forehead, orbit• Basal: nasal cavity or nasopharynx

• Presentation• Sincipital cause pulsating mass near the glabella• Basal: intranasal mass -> airway obstruction (similar to

polyp)

• Diagnosis• CT scan• MRI

• Treatment • Surgery removing the cephalocele and repairing the bural

defect.

NASAL DEFORMITIES

• Septal deviation• Deformities of the external nose

SEPTAL DEVIATION

• A congenital or traumatically acquired bending or bow ing of the nasasl septum

• Symptoms• Bowing, spurring, or ridging of the cartilaginous or bony nasal

septum.

• Diagnosis• External inspection• Anterior Rhinoscopy• Endoscopy

• Treatment• Septoplasty: removing the deviated cartilaginous and bony

portions of the septum along with any spurs and ridges and reimplanting them as needed.

DEFORMITIES OF THE EXTERNAL NOSE

• Congenital or traumatically acquired• Diagnosis: inspection and anterior rhinoscopy• Treatment: corrective surgery

EPISTAXIS

• Cause

• Diagnosis

SOFT-TISSUE INJURIES AND PLASTIC SURGERY

• Z-plasty (Fig. 3.9 a,b): When a wound margin runs perpendicular to the RSTLs, it can be reoriented with a single or multiple Z-plasty and lengthened in the direction of the scar axis.• W-plasty: The principal effect of this technique is

to lengthen the scar.• Broken-line closure: The effect of this technique is

to “optically disperse” the scar, making it more irregular and less noticeable.

SOFT-TISSUE INJURIES AND PLASTIC SURGERY

LOCAL FLAP TECHNIQUES

• a Small “Burow triangles” are excised at the ends of the incisions, allowing the two rectangular flaps to be advanced for defect closure.• b The bilobed flap is a butterfly-shaped

advancement flap used to close a defect.• c The rhomboid flap can be used on the nasal

flank, as illustrated, or on the cheek.• d The skin between the defect and superficial flap

is undermined, and the island flap is pulled into the defect on its subcutaneous pedicle.

REPAIR OF TISSUE DEFECTS

• Traumatic or post-tumor resection• Smaller tissue defects: local flaps• Extensive defects: reconstructive procedures

using autologous transfer.

FRACTURES OF THE NASAL PYRAMID AND LATERAL MIDFACE

• Diagnostic procedure:• Inspection• Palpation• radiographs

• Complications• Hematoma formation• Septal abcess

• Surgical Treatment• Laterally displaced

fragments are reduced by external digital pressure.

• If the nasal pyramid is depressed, the fragments have to be elevated with an instrument from within the nasal cavity.

LATERAL MIDFACIAL FRACTURES

• Cause: blunt trauma to the side of the face.• Affected structures:• Maxillary sinus• Orbit• Zygoma

• Symptoms• Depressed fracture of the zygoma• Limited mouth opening• Fracture of the orbital floor causing diplopia• Sensory disturbances

• Diagnosis• Inspection : • swelling, • asymmetry of the affected facical half,• Enophthalmos (orbital floor)

• Palpation• Frontozygomatic suture• Infraorbital margin• Zygomatic arch

• Sensory testing: CN VII• Radiographs: CT scan• Displaced bone fragments• Herniated orbital contents (hanging drop sign)• Blow-out fracture

• Treatment:• Surgical treatment is unnecessasry for:• Undisplaced• Asymptomatic fractures

• Surgical treatment indicated for:• Displaced• Symptomatic (sensory deficits)

• Treatment of choice:• Reduction and fixation by miniplates and interosseous

wiring.

FRACTURES OF THE CENTRAL MIDFACE AND ANTERIOR SKULL BASE

• Classification:• Central midfacial fractures• Frontobasal fractures

• Symptoms:• Hematoma• Dish face (Le Fort II-III, Escher III)• Cerebrospinal fluid rhinorrhea• Vision loss• Diplopia• Cerebral prolapse• Anosmia

• Diagnosis• Inspection (rhinoscopy, oral cavity, oropharynx,

otoscopy)• Hearing and balance testing• Olfactory testing• Palpation

• CT scan

• fracture of the anterior and posterior walls of the frontal sinuses (arrows) (a)

• a clivus fracture (arrow) that extends anteriorly into the sphenoid sinus (b).

• The coronal scans showair in the cranial cavity (c)

• fracture of the ethmoid roof (d)

• Treatment: surgery

• Apa Penanganan awal pada choanal atresia?• A. reposisi B. reduksi C. intubasi D. surgical repair• Pembuluh darah apa yang paling sering pecah pada

epistaksis anterior?• A. plexus kiesselbach B. a. sphenopalatine • C. a. Labialis D. a. Nasalis• Kapan kita menggunakan broken line closure technique?• A. untuk memanjangi luka • B. untuk minimalisasi bekas luka C. untuk luka bakar • D. untuk luka tajam• Apa tujuan local flap technique?• A. Untuk luka tumpul B. untuk luka tajam• C. untuk luka yang jaringannya perlu ditutupi• D. untuk fraktur frontalis

• Pemeriksa apa yang menegakkan diagnosis pada Fractures of the central midface and anterior skull base?• A. inspeksi B. palpasi C. x-ray D. CT scan