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BACKGROUND: Among the nasal muscles, the levator labii superior alaeque nasi (LLSAN) acts as a transitional muscle that conjugates with other nasal and perinasal muscles. Thus, when treating the nasal region with Botulinum toxin (BTX), it is important to understand local nasal muscular dynamics and how they can influence the muscular dynamics of the entire face. METHODS: This is a retrospective analysis of cases treated by an injection pattern encompassing the face, including nasal muscles. Photographs were taken at rest and during motion (frontal and oblique views), before and after treatment. RESULTS: A total of 227 patients have been treated in the last 18 months with the following results: eyebrow tail lifting, softness of crow's feet, improvement of the drooping of the tip of the nose, and shortening of the lip philtrum when smiling. We present cases illustrating the use of this approach. CONCLUSIONS: Treating the facial muscles globally (including the frontal, corrugators, procerus, orbicularis oculi, platysma, DAO, and nasal muscles) can improve the smile and facial expressions. This is believed to occur because the elevated portion of the upper lip muscle becomes stronger as the nasal part of the LLSAN is paralyzed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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Introducción: La desviación de la punta nasal suele producir alteración estética y funcional nasal. Generalmente, asocia alteraciones morfológicas de los cartílagos alares, además de dismorfia del cartílago septal. Objetivo: Presentar una técnica quirúrgica alternativa para el tratamiento de la laterorrinia en tercio inferior nasal y sus resultados. Material y Método: Se trataron 27 pacientes con una laterorrinia en punta nasal con la técnica del septum bisagra, incluyendo la colocación de uno o dos injertos de expansión. Describimos el protocolo de anamnesis y exploración que seguimos en estos pacientes y la descripción detallada de la técnica quirúrgica. Resultados: En 19 pacientes se utilizó un injerto de expansión unilateral para completar la técnica y en ocho de forma bilateral. Se obtuvo una puntuación media en la escala visual analógica (EVA) de ventilación de 8,3, con una mejoría de seis puntos, y en la EVA de aspecto estético de 8,1, mejorando en 4,6 puntos. Conclusión: la utilización de la técnica del septum bisagra es beneficiosa para el tratamiento de la desviación de la punta nasal, tanto a nivel funcional como estético. Presenta ciertas diferencias frente a otras técnicas descritas. La indicación se debe adecuar a cada paciente de manera individualizada.

Introduction: Deviation of nasal tip usually produces aesthetic disturbance and nasal ventilation decrease. It is usually associated with alar cartilages morphologic disturbances and dysmorphia of the septal cartilage. Aim: To present an alternative surgical technique for treating laterorrhinia in the nasal inferior third and its outcomes. Material and Method: 27 patients with nasal tip laterorrhinia were treated with the hinge septum technique, including the placement of one or two spreader grafts. We describe the anamnesis and exploration protocol that we carried out in these patients and a detailed description of the surgical procedure. Results: Unilateral spreader graft was used in 19 patients to complete the technique, and bilateral spreader graft was used in eight. The average score in visual analogue scale (VAS) related to nasal flow was 8.3, which means an improvement of six points, and in VAS related to aesthetic appearance the score was 8.1, improving 4.6 points. Conclusion: The use of the hinge septum technique is useful to treat the deviation of the nasal tip in a functional and aesthetic way. There are several differences compared to other described techniques. The indication has to be suitable for each patient individually.

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Abstract Introduction Patients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair. Objective To study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea Methods A retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period. Results Of a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%). Conclusion Patients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

Resumo Introdução Pacientes submetidos a tratamento cirúrgico endoscópico de fístula liquórica podem ocasionalmente apresentar coexistência de outras doenças comuns que podem ou não precisar ser tratadas antes do procedimento. Alguns pacientes podem desenvolver nova morbidade nasal relacionada ao tratamento da fístula. Objetivo Estudar a prevalência e o manejo de doenças nasossinusais adicionais em pacientes submetidos ao reparo endoscópico de fístula liquórica. Método Uma revisão retrospectiva de pacientes submetidos ao reparo endoscópico de fistula liquórica foi feita para avaliar a presença de outras morbidades nasossinusais coexistentes no pré‐operatório e no período de seguimento. Resultados De 153 pacientes submetidos ao tratamento endoscópico do fistula liquórica, 97 (63,4%) eram do sexo feminino e 56 (36,6%) do masculino. A maioria dos pacientes (90,2%) tinha entre 21 e 60 anos, com média de 40,8. Verificou‐se que 64 pacientes (41,8%) apresentavam coexistência de morbidade nasossinusal no pré‐operatório, as mais comuns eram desvio de septo nasal sintomático (17,6%), rinossinusite crônica sem pólipos (11,1%) e rinossinusite crônica com pólipos (3,3%). Casos raros de hemangioma septal (0,7%) e papiloma invertido (0,7%) também foram observados. No pós‐operatório, inicialmente obteve‐se fechamento da fístula liquórica em 96,7%, que aumentou para 100% após a cirurgia de revisão nos pacientes com recorrência. A resolução das outras doenças nasossinusais coexistentes foi obtida em todos os pacientes, o seguimento variou de 10 a 192 meses. A ocorrência de uma nova morbidade nasossinusal no pós‐operatório incluiu sinéquias entre a concha média e a parede lateral do nariz (5,9%) e polipose nasossinusal (1,3%). Conclusão Pacientes submetidos a tratamento endoscópico de fistula liquórica podem apresentar coexistência de outras doenças nasossinusais que necessitam de tratamento prévio ou concomitante ao reparo do defeito dural. Outras morbidades nasossinusais que surgem durante o pós‐operatório podem exigir tratamento adicional. Um protocolo para o manejo das condições nasossinusais coexistentes garante um desfecho bem‐sucedido.

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INTRODUCTION: Patients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair. OBJECTIVE: To study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea METHODS: A retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period. RESULTS: Of a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%). CONCLUSION: Patients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

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Campylorrhinus lateralis, also known as "wry nose," is a congenital malformation that mainly affects Thoroughbreds. These horses have a unilateral deviation of the maxillae that may be to one side or the other side, and it causes airway obstruction and dental malocclusion. The choice of treatment is not necessarily operation; however, the treatment of choice, which aims to repair the maxillae deviation, is surgical to improve the horse's respiratory condition and correct the dental occlusion. There are currently no reports describing the first surgical technique for such deformity described by Valdez et al. The present study describes the case of a 2-month-old foal of the Mangalarga Marchador breed that was diagnosed with wry nose. The foal presented with accentuated maxillae deviation to the right side, malocclusion of the incisor teeth, and respiratory noises. After diagnosis and physical examination, the foal was treated by surgical correction of the deviation. To correct the deviation, the bone distraction technique with unilateral osteotomy of the right maxillae and fixation of the external bone distractor was chosen. After 90 days, the bone distractor was removed; consequently, malocclusion of the incisors was greatly improved, and respiratory noises were eliminated.

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OBJECTIVE: To assess the association between dorsal midline skin discolorations, tethering of the spinal cord, and the role of ultrasound screening of these stigmata, focusing specifically on vascular lesions. STUDY DESIGN: We conducted a prospective observational study of infants <6 months of age with suspicious dorsal midline skin stigmata. All were evaluated by physical examination and ultrasound scan. A subset also had a magnetic resonance imaging examination. We examined the association between small, red-shaded discolorations and their respective imaging findings. RESULTS: Among 100 cases with discolorations of vascular types, either isolated or combined with low-risk simple dimples or deviated gluteal folds, none had clinically significant pathologic findings requiring surgical intervention. CONCLUSIONS: Midline lumbar discolorations are more benign than previously thought. Despite the very low association of this group of stigmata with surgical implications, we still recommend the routine use of ultrasound scanning.

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BACKGROUND: Alar cartilage can be very useful for tip and dorsum grafts. Depending on its size and thickness, it can be an important alternative for spreader grafts to improve endonasal functional deficiencies, correct deviated noses, and prevent inverted "V" deformities. Caucasian patients with bulbous tips are the most common candidates to achieve such benefits. It is easy to obtain and to frame into a desired graft. METHODS: The authors describe a surgical technique using the alar cartilages as spreader grafts. All Caucasian patients with bulbous tips who underwent primary rhinoplasty were included. All patients have been evaluated after 3 to 4 months and after 1 and 2 years by aesthetical and functional criteria. RESULTS: Thirty-four patients (28 female and 6 male) underwent this procedure between 2001 and 2015: 94% reported a better airflow, 91% reported very good aesthetic results and were very satisfied 2 years postoperatively, and 12% had nasal deviations that were corrected with a one side double-layered spreader grafts. Two patients presented supra-tip deformities and one patient had a columella scar that was revised surgically. No cases of inverted "V" deformity were reported 2 years postoperatively. CONCLUSIONS: Patients with functional satisfaction and with a straight and smooth dorsum seem to be the most important benefits that were achieved with this technique using alar cartilage spreader grafts, an alternative that can be offered to improve airflow and to prevent deviated and inverted "V" deformities. Level of Evidence: IV, therapeutic study.

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Los precipitadores situacionales del delito (Wortley, 2008) han recibido poca atención por la literatura criminológica en lengua española, y con frecuencia son subsumidos dentro de la perspectiva de la elección racional (Cornish & Clarke, 2003). Sin embargo, el estudio independiente de estos conceptos nos ofrece una oportunidad para profundizar en el proceso mediante el cual los delincuentes pasan al acto en sí. El objetivo de este estudio es sintetizar la evidencia en relación con los precipitadores situacionales del delito, los cuales ofrecen una nueva manera de examinar la interacción entre persona y ambiente en materia de delincuencia. La metodología empleada consiste en una revisión sistemática de la literatura de trabajos empíricos realizados a partir del 2007. Los resultados sugieren que es necesario profundizar en el proceso de toma de decisiones del delincuente desde una perspectiva integrada a nivel teórico, en lugar de hacerlo desde un punto de vista atomizado. Se concluye con una discusión de los resultados, después de considerar las características y limitaciones de los estudios observados.

Situational crime precipitators (Wortley, 2008) have received little attention from criminological literature in the Spanish language and, very often, they have been subsumed into the rational choice perspective (Cornish & Clarke, 2003). However, the autonomous study of these concepts offers us a good opportunity to delve into the process through which offenders move to commit the actual criminal act itself. The objective of this study is to synthetize the evidence with relation to the situational crime precipitators offering a new way to examine the human interaction with the environment in the field of crime. The methodology used envisages a systematic review of empirical literature works carried out since 2007. The results suggest that it is necessary to go further in-depth into the offender’s decision-making process from an integrated theoretical outlook instead of resorting to an atomized point of view. The article is concluded with a discussion on results after considering the major features and limitations of the studies examined.

Os precipitadores situacionais do crime (Wortley, 2008) receberam pouca atenção pela literatura criminológica na língua espanhola, e frequentemente são subsumidos dentro da perspectiva da eleição racional (Cornish & Clarke, 2003). Contudo, o estudo independente destes conceitos oferece-nos uma oportunidade de aprofundar-se no processo mediante o qual os delinquentes passam ao ato mesmo. O objetivo deste estudo é sintetizar a evidência com relação aos precipitadores situacionais do crime, que oferecem uma maneira nova de examinar a interação entre a pessoa e o ambiente na matéria da delinquência. A metodologia usada consiste em uma revisão sistemática da literatura de trabalhos empíricos feitos a partir de 2007. Os resultados sugerem que é necessário aprofundar no processo da tomada de decisão do delinquente de uma perspectiva integrada no nível teórico, em vez de fazê-lo de um ponto de vista atomizado. Conclui-se com uma discussão dos resultados, após ter considerado as características e as limitações dos estudos observados.

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Introducción: Un dorso recto es uno de los principales objetivos para los pacientes que se realizan una rinoseptoplastía. Sin embargo, una resección dorsal excesiva puede traer consecuencias estéticas y funcionales. Objetivos: Describir la experiencia del Departamento de Otorrinolaringología del Hospital Clínico de la Pontificia Universidad Católica de Chile en el manejo del dorso nasal. Material y método: Estudio retrospectivo descriptivo. Se revisaron los protocolos quirúrgicos de los pacientes sometidos a una rinoseptoplastía entre enero de 2010 y junio de 2011. Resultados: Se recopiló un total de 153 pacientes, 67% mujeres. La edad promedio fue de 27,5 años. El abordaje fue abierto en el 78%%. Más del 95%% requirió resección dorsal osteocartilaginosa y osteotomías. El injerto espaciador fue el injerto dorsal más frecuente (51%%). En 101 mujeres y 47 hombres se realizó trabajo de punta nasal (p <0,05). Discusión: En nuestra experiencia el abordaje abierto nos permite obtener una visión más clara de la anatomía. La septoplastía, importante en el manejo de la obstrucción nasal, nos permite además obtener injertos de buena calidad. En pacientes de riesgo de colapso valvular, es importante una resección dorsal conservadora y considerar los injertos espaciadores.

Introduction: A right dorsum is one of the main objectives for patients who undergoes to rhinoseptoplasty. However, excessive dorsal resection can bring aesthetic and functional consequences. Aim: To describe the experience in the management of the nasal dorsum by the Hospital Clínico de la Pontificia Universidad Católica de Chile, ENT Department. Material and method: Retrospective study. All patient's surgical protocols of rhinoseptoplasty between January 2010 and June 2011 were reviewed. Results: 153 patients were collected, 67%% of them were women. The average age was 27.5 years. The open approach was performed in 78%%. Over 95%% of patients required dorsal osteocartilaginous resection and osteotomies. The spreader graft was the most commonly used dorsal graft (51%%). In 101 women and 47 men, nasal tip work were performed (p <0.05). Discussion: In our experience the open approach allows us to obtain a clear vision of the nasal anatomy. Septoplasty is important in the management of the nasal obstruction, and it permits to obtain good quality grafts. In patients at risk of valvular collapse is important a conservative dorsal resection and spreader grafts.

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Deviated nasal septum is associated with compensatory hypertrophy of the inferior nasal concha on the contralateral side. In the past conventional septoplasty was done for the deviated septum, which would improve the patency on the side of deviation but would worsen it on the opposite side due to reallocation of the septum to the midline. The present study of 50 patients unfolds the anatomical composition of the inferior nasal concha based on the computed tomographic scan and help the otolaryngologist to determine whether to add turbinoplasty to standard septoplasty procedure or not.

Un tabique nasal desviado está asociado con una hipertrofia compensatoria de la concha nasal inferior del lado contra lateral. En el pasado se realizaba septoplastía convencional para el tabique desviado, lo que mejoraraba la permeabilidad en el lado de la desviación, pero agravaba ésta en el lado opuesto, debido a la reacomodación del tabique en el plano mediano. En el presente estudio se evaluó en 50 pacientes la composición anatómica de las conchas nasales inferiores, basado en la exploración a través de tomografía computarizada, y de esta manera ayudar al otorrinolaringólogo a determinar si es necesario o no, añadir la plastía de la concha nasal inferior al procedimiento de septoplastía estándar.

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OBJETIVO: Investigar a etiologia, as principais manifestações clínicas e as alterações presentes em crianças de 3 a 9 anos, respiradoras orais, residentes na região urbana de Abaeté (MG). MÉTODOS: Estudo com amostra aleatória representativa da população do município de 23.596 habitantes. Clinicamente, foram consideradas respiradoras orais as crianças que roncavam, dormiam com a boca aberta, babavam no travesseiro e apresentavam queixas de obstrução nasal freqüente ou intermitente. As crianças com diagnóstico clínico de respirador oral foram submetidas a endoscopia nasal, teste alérgico cutâneo e raio X do cavum, hemograma, contagem de eosinófilos, dosagem de IgE total e parasitológico de fezes. Os dados foram analisados utilizando o programa SPSS® versão 10.5. RESULTADOS: As principais causas da respiração oral foram: rinite alérgica (81,4 por cento), hipertrofia de adenóides (79,2 por cento), hipertrofia de amígdalas (12,6 por cento) e desvio obstrutivo do septo nasal (1,0 por cento). As principais manifestações clínicas do respirador oral foram: dormir com a boca aberta (86 por cento), roncar (79 por cento), coçar o nariz (77 por cento), babar no travesseiro (62 por cento), dificuldade respiratória noturna ou sono agitado (62 por cento), obstrução nasal (49 por cento) e irritabilidade durante o dia (43 por cento). CONCLUSÃO: Algumas manifestações clínicas são muito freqüentes na criança respiradora oral. Essas manifestações devem ser reconhecidas e consideradas no diagnóstico clínico da respiração oral.

OBJECTIVE: To investigate the etiology, main clinical manifestations and other concurrent findings in mouth-breathing children aged 3 to 9 years and resident in the urban area of Abaeté (MG), Brazil. METHODS: This study was based on a representative random sample of the town population, of 23,596 inhabitants. Clinical diagnosis of mouth-breathing was defined as a combination of snoring, sleeping with mouth open, drooling on the pillow and frequent or intermittent nasal obstruction. Children with a clinical diagnosis of mouth breathing underwent nasal endoscopy, allergy skin tests and X ray of the rhinopharynx, full blood tests, eosinophil counts, total IgE assay and fecal parasitology. Data were analyzed using SPSS® version 10.5. RESULTS: The main causes of mouth breathing were: allergic rhinitis (81.4 percent), enlarged adenoids (79.2 percent), enlarged tonsils (12.6 percent), and obstructive deviation of the nasal septum (1.0 percent). The main clinical manifestations of mouth breathers were: sleeping with mouth open (86 percent), snoring (79 percent), itchy nose (77 percent), drooling on the pillow (62 percent), nocturnal sleep problems or agitated sleep (62 percent), nasal obstruction (49 percent), and irritability during the day (43 percent). CONCLUSION: Certain clinical manifestations are very common among mouth-breathing children. These manifestations must be recognized and considered in the clinical diagnosis of mouth breathing.

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