Subcutaneous emphysema (SE) is a notably rare complication of surgical procedures, particularly in the context of rhinoplasty. In this report, we present a novel case of recurrent nasal SE following routine open septorhinoplasty in a 59-year-old male. This patient developed persistent subcutaneous air over the nasal dorsum, linked to a fistula tract to the nasal vault, despite initial conservative management with needle aspiration. The patient required surgical intervention to repair the mucosalized fistula tract, leading to a successful long-term outcome. This case highlights a significant gap in the current understanding of SE, as previous reports have primarily focused on periorbital involvement rather than nasal SE and underscores the importance of recognizing nasal SE as a potential complication of rhinoplasty.

Dermoid nasal cysts (congenital nasal median heterotopias) are a rare congenital pathology in children. Yo consider the clinical picture, methods of radiation diagnosis and to study the surgical results of a dermoid cyst of the nose according to the literature. A retrospective review of medical histories with the diagnosis of "Dermoid cyst of the back of the nose and nasal cavity, epidermal cyst of the back of the nose, glioma, encephalocele" was conducted from 2017 to 2022 in the Pediatric Otorhinolaryngological Department of the National Medical Research Center for Otorhinolaryngology of the Federal Medical-Biological Agency of Russia. The case histories were analyzed by the nature of the lesion, the imaging techniques performed, the course of the operation and the results obtained. A total of 16 medical histories were analyzed, the average age was 4.5 years (range 10 months - 15 years), over the past 5 years with a diagnosis of "Dermoid cyst of the nasal dorsum and nasal cavity, glioma, epidermal cyst of the nasal dorsum, encephalocele". All patients underwent magnetic resonance imaging (MRI) in the preoperative period, 14 patients also underwent computed tomography (CT). Of these, 7 had a confirmed dermoid cyst with a fistula, 3 patients without a fistula, 3 patients had glioma, and 1 had encephalocele, 2 patients had an epidermoid cyst. A fistulous opening of the dermoid cyst of the nasal dorsum and nasal cavity was observed in the upper third of the nasal dorsum in 3 children, in the middle third in 2 patients and in the lower third in 2 children. The article presents a scheme for the characteristics of the lesion and the tactics of surgical treatment in comparison with the data of foreign authors. Intraoperatively, intracranial spread occurred in 6 patients. Various surgical approaches for intracranial proliferation and a corresponding literature review are also presented. Catamnestic follow-up ranged from 1 to 5 years (on average, 3.5 years), no relapses or postoperative complications were noted. Nasal median heterotopias are a rare congenital anomaly. Preoperative preparation should include CT and MRI to assess the lesion and exclude intracranial spread. The surgical approach depended directly on the localization of heterotopia and its spread. All patients had a good cosmetic result after the surgical treatment performed by us according to the author's method. Дермоидные кисты носа (врожденные назальные срединные гетеротопии) являются редкой врожденной патологией у детей. Проанализировать клиническую картину, методы лучевой диагностики и изучить результаты хирургического лечения врожденных назальных гетеротопий у детей в течение последних 5 лет. Проведен ретроспективный обзор историй болезни с диагнозом «дермоидная киста спинки носа и полости носа, эпидермальная киста спинки носа, глиома, энцефалоцеле» с 2017 по 2022 г. в детском оториноларингологическом отделении ФГБУ «НМИЦО ФМБА России». Истории болезни проанализированы по характеру поражения, выполненным методам визуализации, ходу операции и полученным результатам. Всего проанализированы 16 историй болезни за последние 5 лет с диагнозом «дермоидная киста спинки носа и полости носа, глиома, эпидермальная киста спинки носа, энцефалоцеле», средний возраст пациентов составил 4,5 года (диапазон 10 мес — 15 лет). Всем пациентам выполнена в предоперационном периоде магнитно-резонансная томография, 14 пациентам — также компьютерная томография. У 7 пациентов подтверждена дермоидная киста со свищевым ходом, у 3 — без свищевого хода, у 3 — глиома, у 1 — энцефалоцеле, у 2 — эпидермоидная киста. Свищевое отверстие дермоидной кисты спинки носа и полости носа наблюдали в верхней трети спинки носа у 3 детей, в средней трети — у 2, в нижней трети — у 2. Представлена схема характеристики поражения и тактики хирургического лечения в сравнении с данными зарубежных авторов. Интраоперационно интракраниальное распространение имело место у 6 пациентов. Рассмотрены различные хирургические подходы при внутричерепном распространении и представлен соответствующий обзор литературы. Катамнестическое наблюдение составило от 1 до 5 лет (в среднем 3,5 года), рецидивов или послеоперационных осложнений не было. Назальные срединные гетеротопии являются редкой врожденной аномалией. Предоперационное обследование должно включать компьютерную томографию и магнитно-резонансную томографию для оценки поражения и исключения внутричерепного распространения. Хирургический подход зависит напрямую от локализации и распространения гетеротопии. У всех пациентов после выполненного нами хирургического лечения по авторской методике наблюдался хороший косметический результат.

Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG). A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated. Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases. The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized. Dacryocystorhinostomy (DCR) describes the creation of a functional pathway from the canaliculi into the nose by means of creating an osteotomy and opening the nasolacrimal sac into the nose. It can be performed via an external or endonasal approach. Obstruction of the excretory lacrimal system results in epiphora (tearing). Depending upon the exact cause and location of the obstruction, specific surgical procedures are used. These may include any of the following procedures: Punctoplasty. Canalicular reconstruction. Canaliculodacryocystorhinostomy. External dacryocystorhinostomy. Endoscopic dacryocystorhinostomy. Conjunctivodacryocystorhinostomy. Dacryocystectomy. This activity will address nasolacrimal duct obstruction (NLDO), which often results in intractable, bothersome epiphora. In longstanding NLDO, mucus can accumulate, resulting in a mucocele in the nasolacrimal sac or even acute or chronic dacryocystitis. Lacrimal surgery to restore tear drainage is usually the definitive treatment and involved one of the types of dacryocystorhinostomy.  History The 12th-Century Andalusian oculist Muhamad Ibn Aslam Al Ghafiqi described the principles of lacrimal surgery in his book "The Right Guide to Ophthalmology." He reported using a small spear-shaped instrument perforating the lacrimal bone in a nasal direction "until blood flows through the nose and mouth with care given not to direct the instrument downward as this would be the incorrect direction." The probe was then wrapped in cotton that was either "dry or soaked in ox fat." This would then be exchanged every day to maintain the patency of the created fistula. This, then, could be described as the first description of creating an opening from the conjunctival fornix into the nose with secondary granulation and epithelialization, thereby forming a functioning fistula. Considering how little was known of the lining of the lacrimal passages and nose and just as little of the three-dimensional anatomy of the lacrimal system, this was a remarkable procedure. Indeed, this principle of fistulization remains the same to date as that of contemporary conjunctivodacryocystorhinostomy. The aim of performing a dacryocystorhinostomy is to create a fistula between the nasolacrimal sac and the nose, thus bypassing any obstruction and allowing passage of tears directly into the nose. The currently accepted technique of external-approach dacryocystorhinostomy (DCR) was first described at the beginning of the 20th century by the Florentine professor of otolaryngology, Addeo Toti in 1904 in the Italian literature, and later modified by Dupuy-Dutemps and Bourguet. Toti's procedure exposed the lacrimal sac via an external incision. He then excised the medial wall of the lacrimal sac and removed the adjoining lacrimal and maxillary bone, together with the mucosa: he achieved this with a hammer and chisel. The skin incision was then closed. Pressure was applied externally to push the lateral wall of the lacrimal sac inward, towards the nasal opening. The aim was to create pressure so that the lateral lacrimal sac became the lateral nasal wall with the direct opening of the canaliculi into the nose. The success was hampered by many factors, including the degree of bone and mucosal removal, secondary granulation formation, adhesions, and adequacy of external pressure. Various improvements in the original procedure were made: Toti modified the procedure in some cases with the removal of a portion of the middle turbinate and made wider bony windows. Kuhnt in 1914 introduced the suturing of the nasal mucosal flaps to the periosteum to reduce granulation tissue. . Dupuy-Dutemps and Bourget modified Toti's operation in 1921 with vertical incisions in the nasal mucosa and the lacrimal sac together with horizontal incisions at the top and bottom ends of the vertical incisions, thereby creating "book-openings." They sutured both the anterior and posterior flaps of the nasal mucosa and the lacrimal sac. In 1933, they further modified their technique by incising the fistula created and probed the passage repeatedly via the lower punctum to reduce granulation and scar tissue and obtained a success rate of 95% in 1000 cases. Ohm, in 1962, essentially described a procedure very similar to the one described by Dupuy-Dutemps and Bourget and sutured the nasal mucosa to the lacrimal sac. . Endonasal DCR was first introduced by Caldwell in 1893, who used an endonasal electric burr to removed the bone once a metal probe had been passed through the canaliculus and into the lacrimal sac. Difficulties included adequate visualization, bleeding, accurate bone, and soft tissue removal. Although the technique was later modified by West in 1910 and Halle in 1914, real endonasal surgical improvements came with the rigid nasal endoscopes, which paved the way for advances in the field of endoscopic DCR. The modern-day approach to endonasal dacryocystorhinostomy was first reported by McDonogh and Meiring in 1989. It now being accepted as an effective approach to DCR in the management of epiphora due to nasolacrimal duct obstruction. While in the 20th century, the most popular approach to DCR was that of an external technique, endonasal DCR, avoiding a skin incision has since been shown to be as successful as the external approach if an appropriate technique is used. It should be emphasized that the term "endonasal" merely describes an approach through the nose rather than a specific technique. It is the evolution and expansion of the many endonasal techniques over time that has led to improved outcomes and greater acceptability and preference for an endonasal approach to DCR surgery. Endonasal DCR was initially performed using rongeurs and was therefore termed "mechanical" endonasal DCR. With the advent of laser technology and the improvement of rigid nasal endoscopes, endoscopic "laser" DCR was popularised. However, lasers were unable to remove the thick bone of the frontal process of the maxilla and root of the middle turbinate, resulting in smaller bony ostea, extensive scarring, and, ultimately, higher failure rates. This led to a shift to the principles of "powered" endoscopic DCR. These principles mimicked those of external DCR, namely a large bony ostium, usually achieved by powered instrumentation, mucosal flaps, and mucosal edge-to-edge apposition, thereby aiming for primary intention healing and minimizing soft-tissue scarring. In an effort to reduce consumable costs, "powered" endoscopic DCR techniques have since evolved to use newer designed instruments, thus avoiding the need for powered instrumentation and, in effect, a shift back to mechanical endonasal DCR, while achieving full sac exposure and still creating mucosal flaps. Since the end of the 20th century, there has been a shift towards endoscopic DCR being accepted as being as safe and effective as external DCR. A large bony ostium (similar to that achieved in an external approach) is essential, and the mucosal flaps created intraoperatively should be well apposed for mucosal anastomosis. Endoscopic procedures that remove the adequate bone for full lacrimal sac exposure, marsupialization, and mucosal flap apposition have very high success rates, ranging between 90% to 100%. A recent study comparing various endoscopic DCR techniques reports equal safety and effectiveness. Endoscopic DCR can also be effectively used in the pediatric population, in patients with craniofacial syndromes and syndromic nasolacrimal duct obstruction and the setting of distal canalicular or common canalicular obstruction. While endoscopic DCRs are on the rise, the majority of DCR surgeries in the U.S.A. remain external. Anatomy An appreciation of precise anatomy is essential to understand the process of DCR surgery. The lacrimal drainage pathway includes the lacrimal punctum (plural: puncti or puncta), the canaliculus and nasolacrimal sac, and finally, the nose. (fig 1) Lacrimal Punctum The punctum is located on the lacrimal papillae, facing slightly towards the globe, on both the upper and lower lids. This small aperture of approximately 0.3mm diameter allows the flow of tears into the canaliculus and is part of the lacrimal pump by means of a siphoning action. Canaliculus The upper and lower eyelids have one canaliculus each. These are lined with nonkeratinized squamous epithelium. The canaliculus initially travels about 2 mm vertically, and then turns horizontally in parallel with the eyelid margin. This horizontal component of the canaliculus is surrounded by Horner's muscle, which is part of the lacrimal part of orbicularis oculi. Horner's muscle contributes to the lacrimal pump function, and any dysfunction of orbicularis oculi may contribute to epiphora due to pump failure. In most individuals (94%), the canaliculus from the upper and lower lid converge and join to form the common canaliculus. The length of the upper canaliculus is about 8mm, whereas the lower canaliculus is about 10 mm. The upper and lower canaliculi each angle slightly posteriorly, but the common canaliculus, in turn, may angle anteriorly. Awareness of this change in direction is essential for safe, atraumatic syringing and probing, which constitutes part of the assessment and pre-operative workup. The common canaliculus then pierces the periorbita and enters the lacrimal sac. However, in some individuals, separate upper and lower canaliculi may enter the sac. The entry into the lacrimal sac most often occurs obliquely, which forms the valve of Rosenmueller. While this is not a valve per se, the angulation of the common canaliculus as it enters the sac prevents retrograde flux and acts in a valve-like manner. Lacrimal Sac and Duct The nasolacrimal sac and duct are continuous rather than separate structures that are lined with non-ciliated columnar epithelium. The sac sits within the lacrimal fossa, which is formed by the lacrimal bone and the frontal process of the maxilla. Its dimensions are 12 to 15 mm in height and 4 to 8 mm anteroposteriorly. The superior fundus of the sac extends 3 to 5 mm above the medial canthal tendon. The nasolacrimal duct extends inferolaterally and posteriorly through the bone for approximately 12 mm, exiting underneath the inferior turbinate. This nasolacrimal duct ostium is located 25 to 30 mm posterior to the anterior nares. The exit of the nasolacrimal duct into the nose is can be round or slit-like and is protected by a mucous membrane covering, called the valve of Hasner or plica lacrimalis. Endoscopic Nasal Anatomy Endonasal anatomy is complex: a detailed discussion is beyond the scope of this chapter. However, a few salient points must be highlighted to understand DCR surgery. The review by Shams et al. is an excellent review of applied endonasal anatomy. The lacrimal fossa is formed by the frontal process of the maxilla anteriorly and the lacrimal bone posteriorly. The fossa is bordered by the anterior lacrimal crest and posterior lacrimal crest. The lacrimal fossa measures about 16 mm vertically is 2 to 4 mm deep with a width of 7 to 10 mm. Variability exists depending upon ethnic origins. The nose has three turbinates, each of which has a corresponding meatus inferior to it. The nasolacrimal duct opening lies within the inferior meatus, but it is the middle turbinate which may guide the DCR surgeon. The middle meatus contains the uncinate process, the bulla ethmoidalis, the frontal recess, and the maxillary sinus ostium. The axilla of the middle turbinate marks the point of the middle turbinate inserting into the frontal process of the maxilla and tends to be a constant anatomical landmark. The lacrimal fossa is situated superiorly, anteriorly and laterally to the axilla of the middle turbinate. It is essential to appreciate the extent of the sac with respect to the middle turbinate to perform successful endoscopic DCR. The sac extends 8 to 10 mm above the superior extent of the middle turbinate and about 4 mm below its inferior border. This means that a significant part of the lacrimal sac fundus lies above the axilla of the middle turbinate, and it is essential to adequately expose this during DCR surgery in order to minimize failure. The maxillary line is the most medial part of the frontal process of the maxilla, and it runs from the axilla of the middle turbinate along the lateral nasal wall ending at the inferior turbinate. It is an important landmark for the placement of mucosal incisions. The uncinate process attaches to the lateral nasal wall at the frontal process of the maxilla. Inferiorly, it attaches to the ethmoidal process of the inferior turbinate. The infundibulum is an area lateral to the uncinate process, into which the maxillary sinus and anterior ethmoid air cells drain. During the creation of the bony ostium as part of endoscopic DCR surgery, the uncinate process helps define the posterior-inferior extent of bone removal involving the lacrimal bone covering the lacrimal sac. Once the uncinate process is encountered, further ostium creation can extend upwards. The agger nasi cells are situated in the lateral nasal wall and are pneumatized to varying extents in different individuals. They may displace the insertion of the middle turbinate medially and can be seen well on computerized tomography (CT), anterior to the middle turbinate. They are usually closely situated near the posterior-superior aspect of the lacrimal fossa and may extend superiorly above the lacrimal fossa.

We aim to compare the modified Veau-Wardill-Kilner push-back technique (VWK) and the Sommerlad intravelar veloplasty (Sommerlad IVVP) in terms of middle ear outcomes and oronasal fistulae frequency in three years old children. For this retrospective cohort study, data were collected and anonymized from consecutive patients with cleft palate (with or without cleft lip) who underwent surgery in our hospital between January 2008 and December 2018. Patients with syndromic diagnoses and patients who underwent surgical treatment elsewhere were excluded. We collected data from 101 children (202 ears) regarding middle ear complications at the age of three, including acute otitis media, middle ear effusion, tympanic membrane retraction, tympanic membrane perforation, tympanic membrane atelectasis and chronic otitis media with cholesteatoma. In addition, the presence of oronasal fistulae and the number of ventilation tubes received by the age of three were recorded. The odds of children having a normal middle ear evaluation were 3.07 (95% Confidence interval (95%CI): [1.52, 6.12]; p < 0.05) times higher when children received Sommerlad IVVP compared to modified VWK. With 40.7% compared to 26.7%, a significantly higher incidence of middle ear effusion was present in the modified VWK group compared to Sommerlad IVVP (X2(1) = 4.38, p < 0.05). Furthermore, this group needed significantly more ventilation tube reinsertions (X2(2) = 12.22, p < 0.05) and was found to have a significantly higher incidence of oronasal fistula (53.5% vs. 17.2%, X2(1) = 14.75, p < 0.05). The latter was significantly associated with a higher need for ventilation tube reinsertion (X2(1) = 7.34, p < 0.05). This study shows superior middle ear outcomes and fewer oronasal fistulae after Sommerlad IVVP compared to modified Veau-Wardill-Kilner push-back at the age of three.

The clinical and pathological data of patients with rhinofacial ulcers were retrospectively reviewed and analyzed to lay the foundation for standardized clinical treatment. We retrospectively analyzed the clinical data, etiology, pathological features, treatment methods, and prognosis of 243 patients with rhinofacial ulcers treated in the Departments of Otorhinolaryngology and Dermatology at six hospitals in Shandong Province, China from July 2014 to October 2021. The clinical characteristics and treatment methods of the rhinofacial ulcers were summarized to provide a basis for standardizing patients' diagnosis and treatment. The male-to-female ratio of the 243 patients was 2.04:1, and their ages ranged from 25 to 91 years. The most common sites were the cheek, nasal dorsum, and upper lip. The common primary diseases were basal-cell carcinoma, squamous-cell carcinoma, and odontogenic fistula, but rare triggers played important roles in some cases, such as infection, autoimmune diseases, and adverse drug reactions. Surgical treatment was feasible for tumor ulcers; 71 patients with basal-cell carcinoma and 50 with squamous-cell carcinoma were treated with Mohs micrographic surgery. During the follow-up period of 1-84 months, most of the rhinofacial ulcers were cured, while natural killer/T-cell lymphoma, angiosarcoma, and melanoma were important causes of death. Various causes may lead to rhinofacial skin ulcers, and some cases lacking specificity of clinical manifestations are easily misdiagnosed in clinical practice. Histopathological biopsy is valuable for confirming the diagnosis, after which correct etiological treatment is very important.