Original Publication, Date 12.06.2005 by Mrs. Dr. Magdalena Grzonka, Siegen on the Website 0f CCMF

Translation by E.Thiele 23.06.2005

See also: "The Ear-Nose-Throat medical (Re-)Habilitation, Effects of the deformities on the ear, Effects of the deformities on the nose, Presentation from Magdalena Grzonka, ENT-specialist in the Kompetenzzentrums (Competence Center) Siegen" , a short summary of the paper presented at the symposium, in an English version.

(See also: CCMF-NEWS report from 25.04.2005.)

Cleft Malformation Of Lip, Alveolus, Palate And Nose

Precondition for the understanding of deformities of the inner and outer nose structures in connection with cleft malformation of lip, alveolus, palate and nose is the knowledge of the embryology.

 The shaping of the face originates out of the 6. branchial arches. Around the stomodeum , which exists already in the 4. till 5. embryonic week, the facial tori are developing:

        Caudally the paired mandibular vault,

        laterally the paired maxillary vault,

        cranially the frontal process with its olfactory placodes surrounded by the

        medial and lateral nose vault.

In the region, where the medial, the lateral nose tori and the maxillary tori are joining, the Hochstetter membrane is created. By a faulty mesenchymal transformation of it a dysgeneses of the lip and outer nose arises.

The dysgenesis of the palate and inner nose is created by a faulty connection of the palatine ridges with one another and with the vomer. This occurs about up from the 9. to the 12. week.

The embryological basis already shows, that the malformation of the lip, jaw and palate also causes a complex malformation of the inner and outer nose.

The structure of the nose:

The nasal dorsum is built up by the os nasale and the triangular cartilage,

the lateral slopes by the processus frontalis maxillae,

the rostral part (vestibule, tip of nose) by the alar cartilages with their medial and lateral pediculus.

The cutaneous nasal bridge is supported by the septum and the crura medialia. The inner nose valves are formed by the junction of the lateral cartilage to the valve cartilages. The nasal septum consists of the rostal cartilaginous and the osseous part and inserts basally in a sulcus of the os maxillare respectively the intermaxilary.

The tasks of the nose regard

        Aerodynamics

        Resonance

        Conditioning of the breathing air

        Mucociliary transport

        Mucosal defence

        Olfactory sensitivity

The problematic nature of the cleft malformation of lip, alveolus, palate and nose

Primary:

Oral and nasal cavity are not separated,

no partition oft the two nasal cavities-

consequences:

        Hyperplasia of the nasal conchae

        Hyperplasia of the adenoids

        Deviated septum

        Mucosa swelling and inflammation

        Diminished nasal diameter

        Increased airway resistance

        Pathologic air stream guidance

        Hypo- or denasality

        Insufficient protection of the deeper air ways

        Aspiration of victuals

        Irritation of the mucosa through saliva and nutriment mash

        Improper swallow and breathing technique

        Pathologic tongue position

        Dyslalia of dento-alveolar and palato-alveolar sounds

Secondary form alterations after primary therapy:

The bilateral cleft malformation of lip, alveolus, palate and nose:

        Foreshortened nasal bridge

        Flat nose tip

        Oblique oval nostrils

        Missing nose entrance sill

        Lateralisation of the nasal wing base bilaterally

        Nose wing deformity

The unilateral cleft malformation of lip, alveolus, palate and nose:

        Deviation of the nasal dorsum

        Septal deviation

        Displacement of the spina nasalis anterior to the unaffected side

        Oblique position, foreshortening of the columella on the cleft side

        s-shaped deformity, flattening and dislocation laterocaudally of the cleftside wing cartilage

        Oblique oval nostril

        Missing nose entrance sill

        Posterior horn of the wing cartilage is not situated upon the triangle cartilage, but leans to the nose inside.

During the surgical correcting functional and aesthetic aspects are to be considered. Intended goal of the operation is the straight positioning of the inner and outer nose. The operation technique affects the following areas:

        Septum deformation

        Deformation of the osseous nasal pyramid

        Malformation of the nose tip

        Dislocation of the cleft side nose wing

Operation goal with the bilateral cleft malformation of lip, alveolus, palate and nose are:

        Extension of the columella

        Approvement of the nose tip projection

        Narrowing of the nose tip

        Narrowing of the nostril with the simultaneous correction of the dislocated nose wing base:

The distinctive dislocation requires an extended mobilization. In order to gain the ultimate symmetry of the nose tip and orifices it is necessary to adjust both, the cartilaginous structures and the soft tissue coating in a side matching manner. Operative measures take place in a region showing differently extended scar tissue through preoperations. It is to be contemplated, the operation being much more complex altogether, than with the standard nose correction. A complete symmetry may not be manageable, and sometimes several interventions are required to gain an optimal result.