Resection of obstructing inferior turbinates following rhinoplasty

Total inferior turbinectomy was carried out in 38 patients who complained of nasal obstruction following rhinoplasty or rhinoseptoplasty and in whom hypertrophied inferior turbinates were found to be the cause of obstruction. Postoperatively, relief of nasal obstruction was reported by 84 percent of patients, while rhinoscopy showed wide, clean nasal airways in 92 percent. Nasal airflow measurements in 32 tested patients showed increased patency in all of them, including 3 who still complained of nasal obstruction postoperatively. The follow-up period ranged from 1 to 7 years (mean 2.8 years). Atrophic changes of the nasal mucosa or chronic purulent infection was not observed in any of the patients. Because the results of partial procedures on the inferior turbinates are often unsatisfactory, I suggest performing total inferior turbinectomy in patients with obstructing inferior turbinates following rhinoplasty.     

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures.The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.     

Nose surgery: how to prevent a middle vault collapse--a review of 50 patients 3 to 21 years after surgery

There is a conception, likely a misconception, that when performing a nasal osteotomy with a concomitant dorsal hump removal, the upper lateral cartilages are detached or damaged and, over the long-term, respiratory difficulties result because of a middle vault collapse or interference with the internal nasal valve. A follow-up of 50 patients between 3 and 21 years postoperatively provides evidence that this can be prevented. The vast majority (82 percent) reported they were breathing very well for an average of 6.5 years postoperatively. Of the authors' own 38 primary rhinoplasty patients, only two patients (5 percent) reported respiratory difficulties. The authors are unable to substantiate that either the osteotomy or the dorsal hump removal was responsible. Of the 12 patients who had their primary rhinoplasty performed elsewhere, six (50 percent) reported respiratory difficulties before the secondary rhinoplasty at this clinic. Furthermore, an appreciable improvement in breathing was reported by 66.7 percent of these patients after the secondary rhinoplasty. The authors conclude that their gentle proper surgical technique, combined with a good understanding of nasal physiology (with respect to the septum, inferior turbinates, and external and internal valves), allows them to perform a concomitant dorsal hump removal and osteotomy without interfering with nasal physiology.     

Comparison between effects of various partial inferior turbinectomy options on nasal airflow: a computer simulation study

Partial inferior turbinectomy is typically performed on patients suffering from chronic nasal obstruction due to hypertrophy of inferior turbinates and is refractory to other more conservative treatments. The effects of the various options of incision performed on the inferior turbinate in terms of the resulting nasal airflow pattern are examined using computational fluid mechanics. The pressure drops across the severely blocked nose and healthy nose models were found to be 32.3 and 12.3 Pa, respectively, whereas the pressure drops across the nasal cavity following one-third turbinate resection, total turbinate resection and front-end resection were obtained as 5.8, 6.1 and 30.5 Pa correspondingly. Based on the total pressure drop results, the one-third resection option seems to be better than the front-end surgery and the total turbinate resection.     

Long-term follow-up of the effectiveness and safety of inferior turbinectomy.

The long-term effectiveness and safety of inferior turbinectomy were assessed in 186 patients who were interviewed and examined 10 to 15 years after surgery (mean 12.3 years). Relief of nasal obstruction was reported by 82 percent of the patients; rhinoscopy showed wide, clean nasal airways in 88 percent. Rhinorrhea was still a problem for 34 percent of patients, and 19 percent were receiving medical treatment for this symptom. Smell acuity had improved in 52 percent of the patients. Before turbinectomy, 32 patients had suffered from bronchial asthma; postoperatively, there was an improvement in 16, and no change in 13; 3 patients reported exacerbation of asthmatic attacks. Atrophic changes of the nasal mucosa and chronic purulent infection were not observed in any of the patients.     

Septal fracture in simple nasal bone fracture

SUMMARY: Nasal bone fractures are the most common type of facial fractures. Previous studies have shown that most nasal fractures involve the septum, which can provide an obstacle to the successful reduction of nasal bone fractures. In particular, septal fractures in combination with simple nasal bone fractures are usually unrecognized and untreated at the time of injury. Furthermore, systemized treatment protocols and diagnostic tools for septal fractures in the case of simple nasal bone fracture have not previously been presented. In this study, the clinical findings of septal fractures in cases of simple nasal bone fracture were correlated with symptoms, signs, and computed tomography findings and assessed statistically. The patterns of septal fractures in simple nasal bone fractures were assessed by direct vision via hemitransfixion incision. Of the 52 patients with simple nasal bone fracture who presented over a 3-year period and were included in this study, 10 were female and 42 were male, with an average age of 33.8 years (age range, 18 to 61 years). Fifty of these patients (96.2 percent) showed septal fractures, and septoplasty or submucosal resection was performed on 41 patients (78.8 percent) who manifested severe septal fractures of perioperative septal grade 3 or higher. Closed reduction of the nasal bone fracture only was performed on the remaining 11 patients. Among the signs evident at physical examination, mucosal tearing was found to be statistically significant for septal fracture. Computed tomography was found to be very helpful in diagnosing septal fracture but could not predict its severity accurately (Spearman correlation coefficient between computed tomography septal grading and perioperative septal grading, 33.5 percent). Therefore, computed tomography could not be used as a definitive diagnostic modality for septal fractures in terms of deciding whether septoplasty or submucous resection was needed. It is evident that septal fractures are frequent in simple nasal bone fractures that are not combined with other facial bone fractures. This study confirms that there are differences between radiologic findings and perioperative findings. To reduce the incidence of posttraumatic nasal deformity, meticulous physical examinations with subsequent septoplasty or submucosal resection are needed in the treatment of simple nasal bone fracture.     

TURBINATES IN THERAPSIDS: EVIDENCE FOR LATE PERMIAN ORIGINS OF MAMMALIAN ENDOTHERMY

The structure and function of the nasal conchae of extant reptiles, birds, and mammals are reviewed, and the relationships to endothermy of the mammalian elements are examined. Reptilian conchae are relatively simple, recurved structures, which bear primarily sensory (olfactory) epithelium. Conversely, the conchae, or turbinates, of birds and mammals are considerably more extensive and complex, and bear, in addition, nonsensory (respiratory) epithelium. Of the mammalian turbinates, only the exclusively respiratory maxilloturbinal has a clear functional relationship with endothermy, as it reduces desiccation associated with rapid and continuous pulmonary ventilation. The other mammalian turbinates principally retain the primitive, olfactory function of the nasal conchae. The maxilloturbinates are the first reliable morphological indicator of endothermy that can be used in the fossil record. In fossil mammals and mammallike reptiles, the presence and function of turbinates are most readily revealed by the ridges by which they attach to the walls of the nasal cavity. Ridges for olfactory turbinals are located posterodorsally, away from the main flow of respiratory air, whereas those of the respiratory maxilloturbinals are situated in the anterolateral portion of the nasal passage, directly in the path of respired air. The maxilloturbinal is also characterized by its proximity to the opening of the nasolacrimal canal. Posterodorsal ridges, for olfactory turbinals, have long been recognized in many mammallike reptiles, including early forms such as pelycosaurs. However, ridges for respiratory turbinals have not been identified previously in this group. In this paper, the presence of anterolateral ridges, which most likely supported respiratory turbinals, is reported in the primitive therocephalian Glanosuchus and in several cynodonts. The presence of respiratory turbinals in these advanced mammallike reptiles suggests that the evolution of “mammalian” oxygen consumption rates may have begun as early as the Late Permian and developed in parallel in therocephalians and cynodonts. Full mammalian endothermy may have taken as much as 40 to 50 million yr to develop.     

Nasal respiratory turbinate function in birds

Nasal respiratory turbinates are complex, epithelially lined structures in nearly all birds and mammals that act as intermittent countercurrent heat exchangers during routine lung ventilation. This study examined avian respiratory turbinate function in five large bird species (115-1,900 g) inhabiting mesic temperate climates. Evaporative water loss and oxygen consumption rates of birds breathing normally (nasopharyngeal breathing) and with nasal turbinates experimentally bypassed (oropharyngeal breathing) were measured. Water and heat loss rates were calculated from lung tidal volumes and nasal and oropharyngeal exhaled air temperatures (T(ex)). Resulting data indicate that respiratory turbinates are equally adaptive across a range of avian orders, regardless of environment, by conserving significant fractions of the daily water and heat budget. Nasal T(ex) of birds was compared to that of lizards, which lack respiratory turbinates. The comparatively high nasal T(ex) of the lizards in similar ambient conditions suggests that their relatively low metabolic rates and correspondingly reduced lung ventilation rates may have constrained selection on similar respiratory adaptations.     

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.     

Human Papillomavirus (HPV) Prevalence in Nasal and Antrochoanal Polyps and Association with Clinical Data

Objectives

The pathogenesis of sinonasal polyposis remains unclear, in spite of several investigative approaches. Antrochoanal polyps, a subgroup of sinonasal polyposis along with allergic- and chronic-inflammatory nasal polyps, mostly originate from the maxillary sinus and develop as a unilateral, pedunculated mass towards the nasopharynx. The human papillomavirus (HPV) is discussed as a possible causative and influencing factor in development and progression of sinonasal polyposis. This study aims to elucidate HPV frequency in nasal polyps and antrochoanal polyps.

Materials and Methods

Genomic DNA from 257 tissue specimens (166 nasal polyps, 39 antrochoanal polyps and 52 nasal turbinates) was subjected to three different established HPV- polymerase chain reaction assays, testing for 37 low- and high-risk HPV. In addition, immunohistochemical analyses for HPV16 were carried out, as well as immunohistochemistry and western blots of p16, a biomarker for HPV induced cancer.

Results

HPV-DNA was detected in 53.8% of antrochoanal polyps, 15.1% of nasal polyps, and 5.8% of nasal turbinates. HPV16 was the predominant type with a detection rate of 76% in nasal polyps and 62% in antrochoanal polyps. Immunohistochemically, HPV positive tissues stained positive for HPV16 antigens and p16 in epithelial cell layers. No significant p16 overexpression was traceable in antrochoanal polyps, nasal polyps and nasal turbinates by western blot. There was no correlation of HPV-status with sex, age, smoking, alcohol consumption or allergic background.

Conclusion

The present study shows a significant frequency of high-risk type HPV16 in antrochoanal polyps. Absence of oncogenic transformation or correlation of the HPV-status with clinical data suggests a latent superinfection, possibly because of anatomical proximity to the oropharynx.     

A new approach to pharmacological effects on ciliary beat frequency in cell cultures—exemplary measurements under Pelargonium sidoidesextract (EPs 7630)

The ciliary beat frequency (CBF) is an important parameter of the defence mechanism of the mucociliary system. We present a new method to determine pharmacological effects on CBF in vitro. Ciliated cell cultures of human nasal epithelium were obtained from partial resection of hyperplastic inferior turbinates in rhinosurgery. An adherent monolayer culture of ciliated cells was present after 10 days in vitro. This study exemplary examines, if a special extract from the roots of Pelargonium sidoides (EPs 7630) has an effect on the CBF in vitro. The influence of three concentrations of the extract (1, 30, 100 microg/ml) was tested. EPs 7630 significantly and concentration-dependently increased CBF to 123% at 30 microg/ml and to 133% at 100 microg/ml compared to the equilibration phase (100%). After rinsing with extract-free medium the CBF of cultured cells returned to nearly the normal range. In future, drug manipulation of the CBF by local application of rhinologics could be a new therapeutical concept in the treatment of upper airway diseases.     

The effect of exercise on nasal uptake of ozone in healthy human adults.

The nose may help protect the lower respiratory tract from the effects of ambient ozone by scrubbing ozone from inspired air. Reductions in both nasal resistance and nitric oxide production with exercise may influence the efficiency of ozone uptake in the nose. Nasal ozone uptake was measured in 10 healthy volunteers before and after 15 min of moderate bicycle exercise. Ozone (0.2 parts/million) was pulled through both nostrils and out of the mouth at a constant flow while the subjects closed their epiglottises. Nasal uptake of ozone was determined by comparing the ozone concentration entering the nostrils to that exiting the mouth. Average preexercise uptake of ozone was 56 +/- 7.8 and 37 +/- 4.9% at 10 and 20 l/min, respectively. These averages did not significantly differ from those immediately postexercise (55 and 37%). Nasal ozone uptake increased significantly (P < 0.001) with decreasing flow rate, but intersubject variability in uptake could not be predicted by nasal volume or cross-sectional areas (as measured by acoustic rhinometry) or endogenous nitric oxide production. However, the percent change in ozone uptake after exercise, within an individual, was correlated with both 1) percent change in nasal volume (r = 0.70 at 10 l/min) and 2) percent change in the rate of volumetric expansion between the nasal valve and turbinates (r = 0.82 at 10 l/min). These results may be useful for assessing human risk associated with ozone exposure during exercise.     

In vivo localization of Staphylococcus aureus in nasal tissues of healthy and influenza A virus-infected ferrets

An in vivo ferret model was used to study the association of Staphylococcus aureus with specific tissues of the nasal cavity in both control and influenza A virus-infected animals. Ferrets were inoculated intranasally with various doses of influenza A3/Hong Kong/1/68 virus. On Days 2, 5, 9 and 14, four or five virus-inoculated and two uninoculated controls were challenged intranasally with a 1-ml volume of radiolabeled S. aureus (3 mg dry wt), a clinical isolate of low passage history. Ferrets were allowed to clear the staphylococci in vivo for 60 to 90 min before sacrifice. The animals were anesthetized, exsanguinated, and decapitated, and the lower jaw was removed. The nasal fossae were exposed by dissection and turbinates from the left nasal fossa were used for virus isolation. The median septum and tissues from the right nasal fossa, which included vestibule and anterior and posterior turbinates, were harvested and processed for radioassay. The percentage of recoverable staphylococci from virus-infected ferrets (Days 2 and 5) was greater than or equal to 10-fold higher compared with controls and animals infected with suboptimal doses of virus; greater than or equal to 76% of the recoverable staphylococci, whether from controls or virus-infected animals, was associated with the anterior turbinates. Histologic examination of the anterior turbinates from virus-infected ferrets, particularly on Days 2 and 5 postexposure to virus, showed that the staphylococci were adhering to desquamating respiratory epithelial cells. In contrast, the anterior turbinates from control ferrets uninoculated with virus and posterior turbinates from both control and virus-infected animals showed no evidence of bacteria adhering to host cells; instead, the staphylococci were found in association with the mucus gel layer of respiratory mucosa. Examination of vestibular tissue showed staphylococci in association with cells of the stratum granulosum in both virus-infected and control animals. Results of this study suggest that the early events of S. aureus interaction with different sites of ferret nasal tissues are effected by different mechanisms, and that the interaction is significantly enhanced by virus-infection.     

The "iatrogenic-hanging columella": preserving columellar contour after tip retroprojection

This article discusses a method for treating the ultraprojecting tip by the resection of columellar skin in open rhinoplasty. Lack of postoperative contraction of columellar skin and soft tissue may result in an "iatrogenic-hanging columella." Columellar skin resection frequently produces its own deformities because of a discrepancy in the width of the columellar base side and the infralobular flap side. The ultraprojecting tip was present in 56 of 660 consecutive rhinoplasty patients (8 percent) over 8 years (1991 to 1998). Of these 56 patients, 48 underwent partial resection of the infralobular skin flap. Of these 48 patients, eight (17 percent) required secondary skin revision of the columellar resection area. The technique was then modified since 1998. Over 2 years, 13 of 129 consecutive rhinoplasty patients (10 percent) were judged to have an ultraprojecting tip. Of these, eight patients were treated with a modification in the technique by resecting skin on the posterior columellar base. No resection areas were revised in the second series. Of the 789 patients in both series, 647 (82 percent) underwent primary rhinoplasties, 126 (16 percent) had secondary rhinoplasties, and 16 (2 percent) had tertiary rhinoplasties. The treatment of excess columella skin adds a subtle aesthetic improvement to the postoperative nasal contour. By resecting skin on the posterior columellar base or the posterior columellar base and, rarely, the anterior flap, an iatrogenic-hanging columella can be avoided.     

Rhinoplasty and endoscopic surgery for functional and inflammatory nasal/sinus disorders

The rhinoplastic surgeon when faced with nasal sinusitis has traditionally delayed aesthetic treatment of the nose, referring the patient to the ear, nose, and throat consultant until complete resolution of the inflammatory condition. Often, under such a scenario, the patient found the ear, nose, and throat procedure to be a traumatic experience that discouraged further surgery of an aesthetic nature. The advent of functional endoscopic sinus surgery has significantly modified the management of paranasal sinus disorders. This minimally invasive, sophisticated procedure can easily be combined with rhinoplasty. More recently, an endoscopic approach has been advocated for management of the septum and lower/middle turbinates. The authors call this functional endoscopic nasal surgery. Functional endoscopic nasal surgery allows a clearer view of the operative field (septum and turbinates), a more accurate correction of nasal obstruction, and better control of bleeding. Thus, endoscopic techniques permit the treatment of functional and inflammatory nasal disorders in a single stage, along with aesthetic improvement. Only the patient with severe sinusitis is unsuitable for combined therapy. The authors present their experience based on 72 consecutive cases of combined functional endoscopic sinus surgery/functional endoscopic nasal surgery with aesthetic rhinoplasty. Complications were minimal and functional failures were limited to 4 percent, whereas aesthetic outcomes remained uncompromised.     

Long-term outcome of autogenous rib graft nasal reconstruction.

Whereas reconstruction of the hypoplastic nose with rib grafting is common, the long-term outcomes of nasal growth and aesthetics are unknown. This study assessed nasal morphometrics, patient satisfaction, and the perception of nasal appearance by others up to 15 years after nasal reconstruction using cantilevered autogenous chondro-osseous rib grafting with rigid internal fixation in children. Records of all patients who received nasal rib grafts between 1983 and 1998 by one senior surgeon were reviewed. Patients in this study were operated on before their late teens and had greater than 1-year follow-up including serial photographic documentation. Nasal growth was determined by comparing anthropometric measurements preoperatively, perioperatively, and postoperatively. Patient satisfaction was determined through a questionnaire that addressed memory, donor-site morbidity, and nasal perception. Independent, blinded skilled observers who reviewed frontal and lateral photographs of the preoperative, perioperative, and postoperative intervals assessed nasal aesthetics. Thirty-two patients who underwent 38 rib graft reconstructions of the nasal dorsum and tip at an average age of 8.8 years constitute the study population. Six patients underwent secondary augmentation. The average interval between initial nasal reconstruction and evaluation for this study was 7.9 years. Comparative anthropometric measurements before and after surgery documented increases in both tip projection (2.3 percent) and nasal length (3.0 percent) and a decrease in nasolabial angle (1.9 percent). Patient satisfaction interview response rate was 100 percent of those whom we were able to contact (28 of 32). The average age at interview was 17.2 years. Most patients recalled the operation and denied recollection of pain. Donor-site long-term morbidity was not an issue for 86 percent of patients. Sixty-four percent of patients remembered their preoperative nasal appearance and 89 percent of these preferred the postoperative change and were not concerned with nasal scars or texture. Almost two-thirds of the patients had fixation screws removed from the nasal dorsum because of skin erosion, easy palpability, or visibility. Although several patients expressed a desire to make minor additional changes to their nose, only one of these elected offered presurgical consultation and none have had such surgery. The postoperative nasal appearance compared with that preoperatively was rated as improved for 66.3 percent of responses, 26.5 percent as unchanged, and 7.2 percent as deteriorated. Cantilevered autogenous chondro-osseous rib graft reconstruction of the nasal dorsum is an effective means of reconstruction for the hypoplastic nose in childhood with respect to morphometric measurements, patient self-perception, and the assessment of nasal appearance by others.     

INTRANASAL INJECTION OF CORTICOSTEROIDS

Intranasal injections into the inferior turbinates of a slightly form of prednisolone TBA (Hydeltra® TBA) into persons with complaint of nasal obstruction gave considerable relief in 78 per cent of cases. Nasal hyperfunction due to seasonal allergic rhinitis, vasomotor rhinitis and secondary nasal edema from sinusitis was the indication for use. No local or general reactions other than a small amount of bleeding at the time of injection was noted. This method allows full utilization of the anti-inflammatory activity of corticosteroids at the local tissue level without producing a systemic effect.     

Resection of obstructing inferior nasal turbinates

We report a series of 88 patients in whom 119 obstructing inferior nasal turbinates were resected for airway obstruction, and who have been followed for 3 months to 3 years. The airways were consistently improved and, to date, there have been no undesirable sequelae.     

Nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases

A retrospective analysis was performed on 1334 patients who underwent nasal reconstruction between 1986 and 2001. The senior author performed all reconstructions in this series after Mohs' histographic excisions. Only secondary reconstructions were performed without a preceding Mohs' excision. Methods of reconstruction, number of operations per patient, locations of defects, and complications were recorded. Using preoperative and postoperative photographs, aesthetic results were reviewed. Basal cell carcinoma was the most common lesion, followed by squamous cancer and melanoma. The average age of the patients was 51 years. Cancers most commonly arose on the dorsum, ala, and tip. Of 1334 cases, a 1.9 percent recurrence rate was documented. The average time between surgery and clinical recognition of recurrence was 39 months. All recurrent lesions were reexcised by the Mohs' technique. Eighty-one percent of reconstructions were completed in three or fewer stages. Seventy-five percent of reconstructions were completed in two stages. Primary dermabrasion or primary laserbrasion using carbon dioxide or erbium lasers was used in nearly every case. Early secondary dermabrasion or laserbrasion was used in a few cases where indicated. A 1.2 percent revision rate was noted (16 patients). Thirteen partial flap necroses required revision. Three patients experienced dehiscence at the donor site of paramedian forehead flaps. A preferred philosophy toward nasal reconstruction is described. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue. Six core principles are advocated that guide efficient and successful nasal reconstruction: (1) maximal conservation of native tissue is advised; (2) reconstruction of the defect, not the subunit, is advised; (3) complementary ablative procedures, such as primary dermabrasion, enhance the final result and decrease the number of revisionary procedures; (4) primary defatting also decreases the number of revisionary procedures; (5) when possible, the use of axial pattern flaps is preferred; and (6) good contour is the aesthetic endpoint.     

Esthesioneuroblastoma: treatment of skull-base recurrence

Thirty-nine patients with esthesioneuroblastoma are reviewed. The presentation of the tumor, symptomatology, investigation, and treatment are discussed. A recommended treatment regimen is outlined. Histologic typing is valueless in predicting tumor behavior. An illustrative and difficult case of recurrent base of skull esthesioneuroblastoma is presented. The resection performed is described, and the problem of extradural oropharyngeal communication is discussed. The solution was to use a temporalis and galeal frontalis flap. Reconstruction was with an external and intraoral prosthesis. Optimal treatment in a fresh lesion is radical surgery with or without radiation therapy. Esthesioneuroblastoma is a rare and often misdiagnosed malignant tumor of the olfactory epithelium. Originally described by Bergen et al. in 1924 as "esthesioneuroepithelioma olfactif," it was introduced into the North American literature by Schall and Lineback in 1951. Since then, fewer than 200 cases have been collected. The various terms used to describe it--olfactory esthesioneuroblastoma, esthesioneurocytoma, and olfactory neuroblastoma--all denote origin from the neural crest. The sensory nerves of smell are short bundles of fibers that originate in the olfactory bulb and pass through the cribriform plate to the olfactory area of the nasal mucosa. This mucosa is located in the most superior part of both nasal fossae. Thus the usual primary sites of occurrence include the superior nasal cavity or nasal septum, and turbinates, the ethmoid, or the cribriform plate, although an extranasal site of origin has been suggested. Symptoms are usually progressive and range from nasal obstruction or epistaxis to diplopia, ocular pain, and headaches in the more advanced disease state.(ABSTRACT TRUNCATED AT 250 WORDS)