(A) Batten graft
(B) Lateral crural strut graft
(C) Septal extension graft
(D) Spreader graft

The correct response is Option B.

Placement of a lateral crural strut graft is most likely to relieve this patient's airway obstruction. The airway obstruction in this patient resulted from collapse of either the external nasal valve, which is formed from the soft tissues of the columella, ala, and nasal floor, or the internal nasal valve, which is the angle formed between the upper lateral cartilage and septum. Other potential causes of airway obstruction include septal deviation, turbinate hypertrophy, and the presence of nasal polyps.

A Cottle test should be performed first to pinpoint the site of collapse. This test can be performed by placing lateral traction on the paranasal skin of the left cheek, which will distract the upper lateral cartilage away from the septum and open the angle of the internal nasal valve. Any improvement in airflow is considered a positive finding and will confirm the diagnosis of obstruction of the internal nasal valve.

However, this patient has negative findings on the Cottle test, thereby localizing the obstruction to the external nasal valve. To correct the nasal valve collapse, a lateral crural strut graft should be inserted between the vestibular lining and the lateral crus of the lower lateral cartilage.

A batten graft, which is placed across the midportion of the quadrangular cartilage of the septum, will not correct either external or internal collapse. A septal extension graft is a large cartilage graft that can be anchored to the septum to control nasal tip projection. A spreader graft is placed along the dorsal septum; it extends posteriorly to improve internal nasal valve collapse.

References
1. Constantian MB. The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg. 1994;93:919.
2. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99:943-952.
3. Gunter JP, Rohrich RJ, Friedman RM. The classification and correction of alar-columellar discrepancies. Plast Reconstr Surg. 1996;97:643.

A 35-year-old man is undergoing surgical correction of a hanging columella. After trimming of the caudal margin of the nasal septum, which of the following is the most appropriate procedure for correction of this deformity?

(A) Caudal resection of the medial crura of the lower lateral cartilage
(B) Placement of a cartilage graft at the nasal spine
(C) Placement of a cartilage strut in the columella
(D) Resection of excess columellar skin
(E) Transposition of an alar cartilage flap into the columella

The correct response is Option A.

The hanging columella deformity typically results from prominence of the caudal margin of the septum or marked convexity of the caudal margin of the medial crura of the lower lateral cartilage. Although resection of the caudal margin alone is often sufficient for correction of this deformity, additional trimming may be required if the medial crura is excessively large. Following exposure of the medial crura, the excess cartilage and a portion of the mucosal lining may be removed.

Placement of cartilage grafts at the nasal spine would only further displace the columella inferiorly. Cartilage strut grafts and alar cartilage flaps are used to correct a hidden or retracted columella. Resection of excess skin and nasal lining is reserved for patients with severe deformities and would not be the most appropriate next step in this patient.

References
1. Daniel RK. The nasal base. In: Daniel RK, ed. Aesthetic Plastic Surgery: Rhinoplasty. Boston, Mass: Little, Brown & Co; 1993:298-304.
2. Rees TD. Unique problems associated with the lip-columella-tip complex. In: Rees TD, Baker DC, Tabbal N, eds. Rhinoplasty: Problems and Controversies. Saint Louis, Mo: CV Mosby Co; 1988:118-123.

A 19-year-old man has nasal obstruction on the left. Physical examination shows hypertrophy of the inferior turbinate. Which of the following is the most appropriate next step in management?

(A) Cottle test
(B) Evaluation for deviated septum
(C) Cephalography
(D) Needle biopsy
(E) Secretory IgA assay

PHOTO

The correct response is Option B.

The most appropriate next step in the management of this 19-year-old man with turbinate hypertrophy is evaluation for septal deviation. Because turbinate hypertrophy is also associated with nasal allergies, it is important to determine the underlying cause of the condition in order to appropriately treat it without causing excessive drying of the nasal mucosa and hemorrhage. The coronal CT scans shown above depict hypertrophy of the left inferior turbinate in a patient who has a mild septal deviation.

The Cottle test is used to diagnose collapse of the internal nasal valve, which is found at the junction of the septum and upper lateral cartilage. The caudal end of the upper lateral cartilage typically forms a 10- to 15-degree angle with the septum; if the angle is less than 10 degrees, air exchange is likely to be obstructed. The Cottle test is performed by placing lateral traction on the paranasal skin of the left cheek, which will distract the upper lateral cartilage away from the septum and open the angle of the internal nasal valve.

Cephalograms are used to identify disproportionate areas of the craniofacial skeleton in patients being considered for orthognathic surgery. The sella-nasion-point A (SNA) and sella-nasion-point B (SNB) angles are measured with this technique. Cephalograms would not be used to measure the inferior turbinates.
Needle biopsy is indicated only in rare instances in patients with intranasal malignancies, which are uncommon. In a patient who is suspected of having a neoplasm of the head and neck, direct nasal endoscopy and CT scans of the head are recommended.

Secretory IgA assay is not used in the diagnosis of turbinate hypertrophy.

References
1. Jackson LE, Koch RJ. Controversies in the management of inferior turbinate hypertrophy: a comprehensive review. Plast Reconstr Surg. 1999;103:300-312.
2. Rohrich RJ, Krueger JK, Adams WP Jr, et al. Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution. Plast Reconstr Surg. 2001;108:536-544.

Which of the following maneuvers performed during rhinoplasty is most likely to result in a saddle nose deformity?

(A) Alar wedge resection
(B) Comminution of nasal bones during infracture
(C) Displacement of spreader grafts
(D) Excessive resection of the upper lateral cartilages
(E) Onlay grafting of the dorsal septum

The correct response is Option B.

Causes of the saddle nose deformity include excessive resection of the nasal dorsum leading to a loss of dorsal support, excessive resection of the septum, fracture of the perpendicular plate of the ethmoid, or comminution of the nasal bones during infracture that results in their displacement in the piriform aperture. Because this deformity is difficult to treat, appropriate measures should be taken to prevent its occurrence. Limiting the amount of dorsal hump that is resected will preserve the periosteal attachments over the nasal bones. A minimum of 1 cm of septal cartilage should remain in the dorsum, and its attachment to the perpendicular plate should not be disrupted. The surgeon should be conservative when reducing the dorsal nose, and infracture should be performed to minimize comminution. Onlay grafting of cartilage or bone is the recommended treatment of saddle nose deformity.

Alar wedge (Weir) resection is performed for correction of flared nostrils and is not likely to affect the contour of the nasal dorsum. Excessive resection of the upper lateral cartilage typically results in collapse of the middle vault; spreader grafts are inserted for correction of this deformity.

References
1. Meyer K, Kesselring U. Secondary rhinoplasty. In: Daniel RK, ed. Aesthetic Plastic Surgery: Rhinoplasty. Boston, Mass: Little, Brown & Co; 1993:819-820.
2. Rohrich RJ, Sheen JH. Secondary rhinoplasty. In: Grotting JC, ed. Reoperative Aesthetic and Reconstructive Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1995:401-510.

Which of the following anatomic structures marks the path of the primary inspiratory nasal current?

(A) Inferior turbinate
(B) Middle meatus
(C) Middle turbinate
(D) Superior meatus
(E) Superior turbinate

The correct response is Option B.

The middle meatus marks the path of the primary inspiratory nasal current; the main flow of air within the nasal airway occurs through this structure. Functions of the nose include respiration, humidification, modification of temperature, filtration of particulate matter, olfaction, and phonation. The physiology of respiration can be characterized according to various laws of physics. Inspiratory flow is directly proportional to the radius of the nasal airway and inversely proportionate to resistance. In addition, total airflow is equal at each end of a tube. The cross-sectional area of the nasal airway is narrowest at the level of the internal nasal valve, and obstruction of the nasal airway is common at this site.

The inspiratory current is normally described as a parabolic curve through the nasal vault. Air enters at the level of the nares and gently arcs at a superior position, above the level of the inferior turbinate.

References
1. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg. 1998;102:856-863.
2. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109:1128-1146.