Isolated Congenital Partial Absence of the Lateral Crural Cartilage — Suleyman Tas PubMed

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. treatment options, and complications that will be encountered in untreated cases. CLINICAL PRESENTATION An 84-year-old debilitated woman presented with a 2-day history of maggots coming out of her nose. Patient had a history of Alzheimer disease and had inadequate personal hygiene. Physical examination revealed erythematous, nasal mucosa, and maggots in nasal cavity (Fig. 1). No maggots were seen by nasal endoscopy because they are photophobic and they prefer to hide in deepest nasal cavity under light. In this case, infestation was not hospital-acquired because there was no hospitalization history within 1 year. Prophylactic antibiotics were initiated for meningitis. Conservative management was applied by packing the nose with a chloroform and turpentine 1,4 mixture followed by mechanical removal of the dead maggots. Irrigation with normal saline was also applied. Patient’s caregivers were educated about prevention of maggot infestation using nets and insecticides. In this case, no further action was taken; however, the patient returned for a follow-up visit at 2 weeks without symptoms. DISCUSSION Nasal myiasis in the community setting is seen more often in tropical and developing countries and is commonly seen in patients who have atrophic rhinitis and patients of poor socioeconomic status and/or living under poor hygienic conditions. 3 The most common families of Diptera responsible for myiasis are the Oestridae (bot flies), Calliphorida e (screwworm flies, blowflies), and Sarcophagidae (carrionflies). 4 Some authors advocate that species identification is essential to help clinicians to predict the patient’s outcome because of the differences between species. 5 In a review of 252 cases of nasal my iasis in India, it was observed that the most common complications were septal and palatal perforations, followed by erosion of the nasal bridge, adjacent areas of face, and the orbit as well as facial cellulites and ulceration of the tonsils and posterior pharyngeal wall. 2 In patients with nasal myiasis, careful patient history, physical examinations, and an appropriate prophylaxis and treatment are important to reduce the risk of complications In our case. Pro- phylactic antibiotics were initiated for meningitis and we have not encountered any complications. Computed tomography scan may be useful to evaluate the extent of bony destruction and tissue invasion. There is no standard protocol as yet for the management of this condition. Many authors believe manual removal of the maggots and debridement of necrotic tissue from the affected site is most effective. The larvae are photophobic and tend to hide in deep parts of nasal cavity even in Eustachian tube Many tech- niques, which aid in removing the maggots from the wounds, are mentioned in the literatures, the most notable being the appli- cation of the site with turpentine oil that expunge the maggots out.6 In this case, the treatment consisted of the removal of larvae by nasal endoscope after packing the nose with a chloroform and turpentine1,4 mixture. Irrigation with normal saline was also applied. Protection of patients a t risk by physical barriers, such as screens or sealed windows, and attention to the hygiene of the patients are mandatory for prevention. Yasin K. Varsak, MD Esra Durmaz, MD Department of Otolaryngology Head and Neck Surgery Konya Numune Hospital Konya, Turkey kursadvarsak@gmail.com Huri S. Yesildemir, MD Department of Otolaryngology Head and Neck Surgery Necmettin Erbakan University Konya, Turkey REFERENCES 1. Arora S, Sharma JK, Pippal SK, et al. Clinical etiology of myiasis in ENT: a reterograde period–interval study. Braz J Otorhinolaryngol 2009;75:356–361 2. Sharma H, Dayal D, Agrawal SP. Nasal myiasis: review of 10 years experience. J Laryngol Otol 1989;103:489–491 3. Sood VP, Kakar PK, Wattal BL. Myiasis in otorhinolaryngology with entomological aspects. J Laryngol Otol 1976;90:393–399 4. Diaz JH. Myiasis and tungiasis. In:Gerald L, Mandell JEB, Dolin Ralphael, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 7th ed Philadelphia: Churchill Livingstone; 2010:3637–3639 5. Lee YT, Chen TL, Lin YC, et al. Nosocomial nasal myiasis in an intubated patient. J Chin Med Assoc 2011;74:369–371 6. McGraw TA, Turiansky GW. Cutaneous myiasis. J Am Acad Dermatol 2008;58:907–926 Isolated Congenital Partial Absence of the Lateral Crural Cartilage To the Editor: Congenital anomalies of the nose are extremely rare and seen with an incidence of 1/20 000 to 1/40 000.1 The majority of these anomalies concomitance to the syndromes or have a familial component.2 There are few studies that demonstrate nonsyndromic, nonfamilial, isolated congenital absence of nasal structure in the literature.3 To date, only 2 aplasia2,3 and 1 hypoplasia4 case of lateral crural cartilage (LCC) were reported. What we know about this topic is from case studies. The author presents an isolated, nonsyndromic, nonfamilial congenital partial absence of left LCC. To our best knowledge, this study is the first isolated partial absence of LCC. FIGURE 1. A maggot (white arrow) is shown in the nasal cavity. The Journal of Craniofacial Surgery /C15 Volume 26, Number 7, October 2015 Correspondence # 2015 Mutaz B. Habal, MD 2231

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. A 22-year-old woman was admitted to our clinic for a nasal airway obstruction and shape deformity of nose. She had no history of nasal trauma, previous surgery, hyposmia, or epistaxis. The physical examination revealed a clear hump, external deviation to left side, mild septal deviation to right side, pronounced nostril asymmetry, and a notch on the left alar area. In the Collen test, there was a total collapse on the left side that indicated to external valve insufficiency. A close approach septorhinoplasty was performed. After nasal hump was removed and septum deviation was corrected, LCCs were exposed via delivery technique. A 2 /C2 1c m2 defect of the left crural cartilage was detected 1 cm beyond the left dome. This structural anomaly was reconstructed with lateral crural strut graft and rim graft was placed to fix the external valve insufficiency. Interdomal and intradomal sutures were placed for correcting the tip and nostril asymmetry. Nasal tip support was achieved with deep superficial musculoaponeurotic system layer suture, 5 which was described before by the author (S.T.). The operation was finished uneventfully and the result of postoperative 12 months was quite satisfactory in terms of function and esthetic (Fig. 1). The LCC and external nasal walls occur from the pair of lateral nasal processes between the fourth and eighth weeks of gestation. 1 Therefore, local pressure or a vascular accident may be related to this presented anomaly. 2 In 2004, Losee et al 1 created a classifi- cation scheme for the congenital nasal anomalies that has four subgroups as hypoplasia/aplasia of parts, hyperplasia/duplication of parts, atypical clefts, and neoplasms/vascular anomalies. There are three reported cases of isolated LCC anomalies in the literature. Adelson et al2 reported a total aplasia of left LCC in 2008. Temiz et al3 reported a total aplasia of right LCC in 2014. Barutca et al 4 reported a partial absence of left LCC in 2011; however, it is more accurate to describe anomaly as hypoplasia as seen from the presented photos in the report according to Loose et al 1 classifi- cation. This classification includes the hypoplasia and aplasia of cartilages in type I, but it does not describe the partial absence of the cartilages so it should be redesigned in the future with insight of new informations. The rhinoplasty surgeons should be prepared for unexpected congenital anomalies even if a mild shrinkage is subjected. In spite of the limited knowledge about this extremely rare anomaly, it could be repaired with current techniques. Su¨leyman Tas¸,M D Department of Plastic, Reconstructive and Aesthetic Surgery Rize Training & Research Hospital Rize, Turkey drsuleymantas@live.com REFERENCES 1. Losee JE, Kirschner RE, Whitaker LA, et al. Congenital nasal anomalies: a classification scheme. Plast Reconstr Surg 2004;113:676–689 2. Adelson RT, Karimi K, Herrero N. Isolated congenital absence of the left lower lateral cartilage. Otolaryngol Head Neck Surg 2008;138: 793–794 3. Temiz G, Yes¸ilog˘lu N, Sarici M, et al. Congenital isolated aplasia of lower lateral cartilage and reconstruction using dorsal hump material. J Craniofac Surg 2014;25:e411–e413 4. Barutca SA, O¨ rerog˘lu AR, Usc¸etin I, et al. Isolated congenital partial absence of the left lower lateral nasal cartilage: case report.Ann Plast Surg 2011;67:662–664 5. Tas¸ S. A new way for supporting tip projection in closed rhinoplasty: using the medial deep SMAS layer. Plast Reconstr Surg 2014;133: 76e–77e