Ranko Mladina

Nasal septal deformities in ear, nose, and throat patients: An international study

PURPOSE The purpose of this study was to investigate the incidence and characteristics of nasal septum deformities in ear, nose, and throat (ENT) patients in various geographic regions in the world. MATERIALS AND METHODS Anterior rhinoscopy without nasal decongestion was performed in 17 ENT centers in 14 countries. The septal deformities were classified according to the classification system proposed by Mladina. RESULTS A total of 2589 adult ENT patients (1500 males and 1089 females) were examined. Septal deformities were found in 89.2% of subjects. Left-sided deformities were slightly more prevalent than right-sided deformities (51.6% and 48.4%, respectively). The most frequent type of deformity was type 3 (20.4%). Straight septum was found in 15.4% of females and 7.5% of males. CONCLUSIONS Almost 90% of the subjects showed 1 of the 7 types of septal deformity. There were no statistically significant differences in the incidence of their appearance among particular geographic regions. Type 3 was the most frequent type. Straight septum was twice as frequent in females than in males.

Necrotizing fasciitis after peritonsillar abscess in an immunocompetent patient.

Cervical necrotizing fasciitis (CNF) is a rapidly progressive, severe bacterial infection of the fascial planes of the head and neck. Group A beta haemolytic Streptococcus spp. (GABHS), Staphylococcus spp., or obligatory anaerobic bacteria are the most common causative pathogens. The disease usually results from a dental source or facial trauma. Extensive fascial necrosis and severe systemic toxicity are common manifestations of CNF. Review of the literature reveals only seven such cases, with four successful outcomes. The authors present the case of a 50-year-old immunocompetent female with CNF arising from a peritonsillar abscess. Intravenous immunoglobulins in conjunction with surgery and antibiotics were used successfully. The authors also suggest the importance of the early diagnosis, aggressive surgical debridement, broad-spectrum antibiotics, and possible usefulness of the intravenous immunoglobulins in the treatment of CNF, especially when the disease is associated with toxic shock syndrome.

Congenital Bony Fixation of the Malleus

Bony fixation of the malleus seems to be one of the most controversial clinical entities among various congenital disorders of the auditory ossicles. According to various theories, it could be caused by trauma, chronic infection of the ear, otosclerosis or even development failures in the tympanic cavity itself. Histological analysis of 1,108 temporal bones showing a normal middle ear structure was performed. All bones were cut in serial sections of 20 microns. Audiograms and the data on ear trauma or chronic infection were analysed from case histories belonging to each bony specimen. Bony fixation of the malleus was found in 14 cases. It was almost always unilateral. The most frequent site of the fixation was the lateral epitympanal wall. The forms of fixation differed from a thin bony lamella to a solid bony bridge. The mallear ligaments were not involved in any case. No relationship to chronic ear infection, ear trauma or otosclerosis was found. Only a slight conductive hearing impairment up to 20 dB was recorded in 6 out of 14 cases. The most probable predisposing anatomical factors for the onset of the bony fixation of the malleus and the most recent preoperative diagnostic possibilities are discussed.

Nasal Polyposis: From Pathogenesis to Treatment, An Update

Nasal polyps (NP) are common benign degeneration of nasal sinus mucosa with a prevalence around 4% in the adult population. The causes are still uncertain but there is a strong association with allergy, infection, asthma and aspirin sensitivity. Histologically, the presence of a large quantity of extracellular fluid, mast cell degranulation and eosinophilia has been demonstrated. Typically the patients show nasal obstruction, anosmia and rhinorrhoea. Nasal endoscopic examination and CT imaging allow evaluation of the disease extension. A combined medical and surgical treatment is recommended for symptoms control in preventing symptomatic NP recurrence. We will review the current knowledge in the pathogenesis and treatment of this complex disease entity.

Correlation between the minimal cross-sectional area of the nasal cavity and body surface area: preliminary results in normal patients.

Nasal symptoms often are inconsistent with rhinoscopic findings. However, the proper diagnosis and treatment of nasal pathology requires an objective evaluation of the narrow segments of the anterior part of the nasal cavities (minimal cross-sectional area [MCSA]). The problem is that the value of MCSA is not a unique parameter for the entire population, but rather it is a distinctive value for particular subject (or smaller groups of subjects). Consequently, there is a need for MCSA values to be standardized in a simple way that facilitates the comparison of results and the selection of our treatment regimens. We examined a group of 157 healthy subjects with normal nasal function. A statistically significant correlation was found between the body surface area and MCSA at the level of the nasal isthmus and the head of the inferior turbinate. The age of subjects was not found a statistically significant predictor for the value of MCSA. The results show that the expected value of MCSA can be calculated for every subject based on anthropometric data of height and weight.

The two holes syndrome.

Background Defects in the fontanel region of the lateral nasal wall have been described in the literature as “accessory” or “secondary” ostia. The authors consider them a sign of chronic maxillary sinusitis. Along with mucus recirculation between the natural ostium and the fontanel defect, we call it the Two Holes Syndrome. The aim of this study was to determine the incidence of fontanel defects in patients with chronic rhinosinusitis (CRS) and in healthy subjects. Methods Eighty-eight hundred seventy-nine outpatients with CRS were examined by means of nasal fiberendoscopy. The control group consisted of 1442 healthy volunteers with no previous history of CRS. Results Defect in the posterior fontanel was found in 1713/8879 CRS patients (19.3%). It was bilateral in 1165 cases (68.03%). Defect in the anterior fontanel was found in 54 patients (0.61%). The circulating mucus ring was identified in 162 patients with fontanel defects (9.17%). The defect in the posterior fontanel was found in 7/1442 healthy volunteers (0.48%). It was never bilateral, the circulating mucus was not observed and defect in the anterior fontanel was not found. Conclusion Posterior fontanel defects were found more frequently in CRS patients than in healthy subjects. These defects have been clinically related to chronic infection of the maxillary sinus and should not be called “accessory” or “secondary” ostia. CRS with defects of the fontanel region and mucus recirculation can promote a number of health disturbances (chronic postnasal drip, headache, and cough). We named this entity the Two Holes Syndrome.

Bilateral respiratory epithelial adenomatoid hamartoma of the olfactory cleft penetrating into the endocranium.

Respiratory epithelial adenomatoid hamartomas (REAHs) of the nose and paranasal sinuses are relatively rare. These tumors usually do not extend over the boundaries of the nose and sinuses. The authors presented a 65-year-old man experiencing progressive hyposmia, followed by intermittent stubborn headache. The symptoms lasted for almost 2 years and were getting worse very slowly. Fiberendoscopy showed relatively discrete polypoid tissue occupying the olfactory cleft bilaterally. The computed tomography and magnetic resonance imaging suggested the possible lack of the cribriform plate and the unity and uniformity of the tissues located both in the endocranium and high in the nasal cavity. The clinical picture resembled very much a esthesineuroblastoma. The patient underwent endoscopic sinus surgery under the general hypotensive anesthesia. Frozen sections during the surgery showed REAH. The entire tumor was removed in a piece meal way, including both olfactory bulbs because they were involved within the pathologic tissue as well. This case showed that REAH could also be a locally aggressive process, penetrating even into the endocranium.

Training Cerebrospinal Fluid Leak Repair with Nasoseptal Flap on the Lamb's Head

Background: One of the major challenges of cranial base surgery is reconstruction of dural defects and cerebrospinal fluid leak closure. Various grafting methods have been used for smaller skull base defects with great success. The indications for endoscopic reconstruction have recently evolved to encompass much larger breeches in the skull base following tumor removal, thus emphasizing the need for vascularized tissue flaps for reconstruction. Methods: Some authors proposed a pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium, which is very vascularized and has quite a large surface. It is also long enough to easily cover even larger defects of the skull base. The elevation of a nasoseptal flap is based on a particularly advanced surgical technique and thus requires proper training before being performed in a real patient. Results: Anatomical differences between human and lamb heads were observed and explained although they do not affect the procedure of the elevation of the nasoseptal flap. Conclusions: The lambs head has been shown to be an ideal model for the adequate training of the surgical skills required for this demanding procedure.

Unilateral cleft lip/palate children: the incidence of type 6 septal deformities in their parents.

BACKGROUND The overall incidence of pathological septal deformity has been found to be significantly higher in unilateral cleft lip/palate (UCLP) children than in control children. Of the seven types of septal deformity according to Mladinas classification, type 6 has been found to be the most frequent in UCLP children, occurring in only 3.7% of the control children. OBJECTIVE To investigate the incidence of type 6 septal deformity in the parents of UCLP children. PATIENTS AND METHODS UCLP children (N=62) and their parents (N=91) were examined for type 6 septal deformities. RESULTS Type 6 was found in at least one parent of a UCLP child in 58% of cases. However, it was not found in the parents whose UCLP children did not show a type 6 septal deformity. CONCLUSION Type 6 septal deformity is almost a rule in children suffering from UCLP. Type 6 was not seen in the parents whose UCLP children did not show a type 6 septal deformity. There is a morphogenetic predisposition for the development of CLP in children whose parents carry a type 6 septal deformity.

An unusual case of heminasal aplasia: proboscis lateralis or cystic teratoma?

Unilateral aplasia of the nose is a rare congenital malformation. It is often associated with other malformations of the facial region, including abnormalities of the eye and lacrimal system, proboscis lateralis, and facial bone malformations. The authors present a case of heminasal aplasia in a 4-year-old boy who underwent surgery immediately after birth because of right-sided proboscis lateralis. A huge hemispheric tumefaction was occupying a large part of the right orbit, medial canthus, and frontonasal region of the face, causing lateroinferior protrusion of the eyeball. The right half of the external nose was aplastic. The patient was operated on by an external approach. The pathohistological findings from the top of tumefaction revealed cystic teratoma. The possible backgrounds for the onset of the tumefaction are discussed in two main directions: the cystic form of the regrowth of the remnants of inadequately excised proboscis lateralis and cystic teratoma of the ethmoidal sinus.