Thomas S. Kuehnel

The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS).

The frontal recess and frontal sinus anatomy can vary from simple to complex. The variations in the anatomy of the frontal recess and frontal sinus are considerable but almost all variations can be classified if the various cell patterns are analyzed. This consensus document was developed to improve the ability of the surgeon to understand these possible variations, plan the surgery, and communicate these complexities when teaching or reporting outcomes. Once the surgeon understands the anatomical pattern of the frontal sinus and recess cells, the extent of surgery can be planned. This document presents a classification of the extent of surgery based on the anatomical classification.

Clinical anatomy of the nasal process of the frontal bone (spina nasalis interna)

OBJECTIVES: During endonasal frontal sinusotomy with the sharp spoon, a solid piece of bone is frequently encountered anterior to the neo-ostium. This bone may be referred to as the nasal process of the frontal bone or internal nasal spine (spina nasalis interna). A prominent spina may render an extended sinusotomy difficult and may call for use of the drill. A series of anatomic measurements is presented to illustrate the 3-dimensional anatomy of the spina nasalis and the regional anatomy. METHODS: A maximum endonasal frontal sinusotomy (Draf type I-II procedure, nasofrontal approach type II) was performed on 36 anatomic specimens by means of a sharp spoon. The dimensions of the remaining nasal spine were measured subsequently together with the anterior-posterior diameter of the inferior frontal sinus, the thickness of the anterior frontal sinus wall, and the distance from the neo-ostium to the anterior ethmoidal artery. RESULTS: The individual microanatomy of the medial floor of the frontal sinus showed a wide range of variation. The average height of the individual spine was 10 mm, the maximum depth 6 mm. A correlation was found between the nasofrontal angle of the specimen and the anterior-posterior dimension of the spine: the more acute the angle, the thicker the spine. In three quarters of the cases, the neo-ostium was separated by just one anterior ethmoidal cell from the anterior ethmoidal artery. CONCLUSIONS: The presented investigations provide the surgeon with quantitative data on the individual anatomy of the nasal spine and offer additional information for selecting the appropriate surgical procedure in the individual patient.

An intradermal nevus of the external auditory meatus

We herein describe a rare case of an intradermal nevus arising in the external auditory meatus. A 36-year-old woman presented with progressive hearing loss on the right ear, and otomicroscopic examination revealed the presence of a large, violaceous, dome-shaped, papillomatous lesion originating from the posterior wall of the external canal of the right ear. Upon excisional biopsy, the tumor was diagnosed as an intradermal nevus. Thus, this is a unique case of intradermal nevus obstructing the external ear canal with the patient presenting with progressive hearing loss. The possibility of a benign nevomelanocytic nevus should not be underestimated when evaluating a lesion obstructing the ear canal, and all melanocytic nevi should be excised instead of biopsied to rule out melanoma.

The nasal cycle during wakefulness and sleep and its relation to body position

To compare the occurrence, duration, and relative amplitudes of the nasal cycle (NC) during wakefulness and sleep, and to investigate the relationship of the NC to body position.

Prelamination to reconstruct internal nasal lining.

The reconstruction of internal lining in nasal reconstruction is critical to the final result. Most established techniques carry important drawbacks, which include limited available lining surface area, compromise of nasal physiologic function, or donor site morbidity. In this report, we demonstrate a technique that is reliable, technically facile, and allows for the reconstruction of large surface areas: the creation of a bilaminated forehead flap by in situ split-thickness skin grafting. The use of the bilaminated forehead flap in subsequent reconstructive steps allows for dependable reconstruction. All relevant technical steps are illustrated in detail.

Nasal Tip Recontouring in Primary Rhinoplasty: The Endonasal Complete Release Approach

OBJECTIVE Surgery of the nasal tip is a particular challenging aspect of rhinoplasty. We describe a surgical concept in nasal tip surgery that is novel in certain aspects. It combines maneuvers that are typically reserved for the open approach with the minimally invasive concept of endonasal rhinoplasty. METHODS Integral to the concept are the complete dissection and delivery of the lateral crus, repositioning of the dome, placement of alar strut grafts that extend far medially, and lateral advancement of the lateral crus. RESULTS This concept of nasal tip recontouring through the endonasal complete release approach is illustrated in detail. Representative cases are displayed, and outcomes in a population of 100 consecutive young female primary rhinoplasty patients are presented. CONCLUSIONS The concept allows for excellent cosmetic and functional outcomes through a minimally invasive approach with preservation of a naturally soft nasal tip. Patient comfort is maximized by reduced swelling, avoidance of nasal packing, and obviation of external incisions.