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JOURNAL FOR CONTINUING MEDICAL EDUCATION

Year XII • No. 44 (3) 2019 • DOI: 10.26416/ORL.44.3.2019

ISSUE
THEME
NOSE &
RESPIRATION

Bucharest

RHINOLOGY
Transcranian endoscopic
approach in a frontal
polyposis
page 7

 rontal sinus osteoma –

F
case report
page 12

ATLAS
Particular CT scan
aspects in ethmoid
anatomy
page 40
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 Journal for continuing medical education
“What you do today can improve
all your tomorrows”
Dear colleagues,
We have a very intense and exciting
scientific autumn, with important ENT
conferences. After the successful congress
of the Romanian Society of Rhinology
and the first congress of the Romanian
Society of Audiology and Communication
Pathology, the European Symposium on
Pediatric Cochlear Implantation (ESPCI)
will follow, on 16-19 October, 2019.
It is a great honour for the Romanian
medical world – especially for the ENT
community – to host a conference of such
magnitude and high scientific level.
The Romanian ENT journal ORL.ro
joined ESPCI, and we have chosen for
this issue original articles with another
topic than otology, audiology or cochlear
implant: the nose and its functions.
We hope you will find interesting and
useful these clinical cases, and keep our
journal after the ESPCI conference.
We welcome you all in the Romanian
scientific community at the 14th Euro-
pean Symposium on Pediatric Cochlear
Reclamă ORL 44(3)0101
Ralph Marston
Implantation, to find new ideas for fu-
ture clinical and research activity, to Assoc. Professor
discuss with MASTERS in cochlear im- Mădălina Georgescu
plantation about our difficult cases and Editor-in-chief
challenges.
New topics are now the subject for
discussion – congenital single-sided
(SSD) deafness in newborns or small
children, or acquired SSD in adults, most
beneficial early audiological diagnostic
protocols, novelty in programming, te-
lemedicine, challenging rehabilitation,
long-term processes and, of course, ves-
tibular system awareness. All these will
be addressed by outstanding lectors in
instructional courses, round tables or
hands-on labs.
The future of people with hearing
loss is in our hands, and we should get
the best form literature and scientific
meetings.
content Year XII • No. 44 (3) September 2019

EDITOR-IN-CHIEF
Assoc. Professor Mădălina GEORGESCU
RHINOLOGY DEPUTY EDITOR-IN-CHIEF
Dr. Loredana MITRAN
7 Transcranian endoscopic approach in a frontal polyposis EDITORIAL BOARD
Professor Silviu ALBU, Professor Traian ATAMAN
Bogdan Mocanu, Silviu Oprescu Professor Sorin BASCHIR, Professor Gheorghe COMŞA

12 Frontal sinus osteoma – case report

Professor Stan COTULBEA, Professor Dumitru CRISTEA
Professor Emil MĂRGINEANU, Professor Dan MÂRŢU
Professor Gheorghe MUHLFAY, Professor Cristian STAN,
C. Drăgulescu, M. Chiţac, A. Weisman, M. Condrat, X. Dolghii, E. Onisâi, Assoc. Professor Sebastian COZMA
M. Vasilca Assoc. Professor Luminiţa RĂDULESCU
Assoc. Professor Corneliu ROMANIŢAN

16 Carcinoma of the nasal vestibule – comments on a clinical case Assoc. Professor Carmen STAN
SL Adriana NEAGOȘ, SL Raluca Ioana TELEANU
Mihail Tuşaliu, Lavinia-Georgiana Ilinca, Iulia Tiţă SL Daniel Mihai TELEANU, Ass. Professor Mihai TUȘALIU
Dr. Victor Gabriel CLĂTICI, Dr. Irina GHEORGHIU
Dr. Elena CRISTESCU, Dr. Alexandru PASCU, Dr. Daniela SAFTA

INTERDISCIPLINARY
Dr. Celesta DRĂGULESCU
Dr. Valentina Ruxandra MOROTI CONSTANTINESCU
Dr. Arthur WEISMAN, Dr. Cristiana OPREA
24 Follow-up in advanced basal-cell carcinoma ACADEMICIANS
Professor Ion ABABII, Professor Constantin DUMITRACHE
Sorin Ibric-Cioranu, Vlad Petrescu-Seceleanu Professor Mircea IFRIM, Professor Constantin POPA

28 Study on the prevalence, diagnosis, therapeutic management

Professor Victor VOICU
INTERNATIONAL EDITORIAL BOARD
and complications of supernumerary teeth Professor Patrice TRAN BA HUY (France)
Professor Jeff MULDER (The Netherlands)
Andreea Dona Iordan-Dumitru, Agnes Katherine Lackner, Andrei Kozma, Dr. Bernard ARS (Belgium)
Horia Lăzărescu, Doriana Agop Forna, Vasilica Toma PEER REVIEW
Professor Romeo CĂLĂRAŞU
36 The use of endodontic posts in odontal restorations of non-vital teeth Professor Elena IONIŢĂ, Professor Mărioara POENARU
Professor Valerie LUND (France)
Irina-Maria Gheorghiu, Paula Perlea, Claudiu-Gabriel Ciolan, Loredana Mitran, Assoc. Professor Mădălina GEORGESCU
SL Vlad Andrei BUDU
Mihai Mitran, Alexandru-Andrei Iliescu Ass. Professor Payam BEHZADI (Iran)
Dr. Loredana MITRAN, Dr. Daniela VRÎNCEANU
Dr. Ciprian ENĂCHESCU (France)
ATLAS EDITORIAL SECRETARIES
Dr. Anca CIOBOTARIU, Dr. Daniel MIREA
40 Particular CT scan aspects in ethmoid anatomy Dr. Mircea ROMANIŢAN
DTP
Alexandra Gheorghe, Silviu Crăc, Alexandru Panfiloiu, Vlad Budu Ioana BACALU
PROOFREADING

EVENTS Florentin CRISTIAN

PHOTOPROCESSING

46 Primul Congres Naţional al tinerei Societăţi Române de Audiologie Radu LEONTE

și Patologie a Comunicării/The First National Congress of the young

Romanian Society of Audiology and Communication Pathology
Sebastian Cozma

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rhinology
Transcranian endoscopic
approach in a frontal polyposis
Abstract
We present the case of a 62-year-old patient with a large
bilateral frontal sinus tumor, with severe headache and
a partial destruction of the left lamina papyracea and of
the posterior wall of the right frontal sinus. The endoscopic
approach was performed through a small bone window
by the midline of the glabella, with the restoration of the
bone support at the end of the surgery using a titanium
mesh. Although the surgical staff has a lot of experience in
doing the endoscopic transnasal approach, there are some
cases where the transnasal route cannot safely solve certain
pathologies. This is the reason why the authors wish to
illustrate the need of using an approach that will ensure a
proper management of any kind of complications that can
occur during surgery, specific to these tumors (bleeding,
cerebrospinal fluid leak). In this case, the transcranial
endoscopic approach was the best solution.
Keywords: frontal sinus, tumor, external endoscopic
approach
Submission date:
28.07.2019 Polipoză de sinus frontal operată prin abord endoscopic transcranian
Acceptance date: Suggested citation for this article: Mocanu B, Oprescu S. Transcranian endoscopic approach in a frontal polyposis. ORL.ro. 2019;44(3):7-10.
10.08.2019
A 62-year-old patient, S.I., came to our hospital
with an intensive headache syndrome, treatment-
resistant, which had been known for several years
and had worsened in the last 2-3 weeks. Three years
ago (May 2016), in another ENT service, the patient
underwent a curative surgery for bilateral fronto-
ethmoido-sphenoidal rhinosinusitis. According to
the medical discharge presented by the patient, the
frontal sinus approach used was of the Draf I kind,
without exploring the frontal sinus cavity.
The CT/MRI scans on admission revealed the
existence of a tumor-like formation, with intense
gadolinium (hypercaptant), that had ballooned both
frontal sinuses, and destroyed the intersinusal wall.
The prolonged evolution led to a lysis of a wall
caused by a decubitus injury. This explained the in-
timate tumoral contact with the dura mater through
an 8-mm bone breach in the posterior wall of the
right frontal sinus.
Also, the tumor protruded through the left orbit
by an erosion of the left lamina papyracea, with the
appearance of a discrete inferior and external exo­
phthalmia in the left eye. The MRI revealed that the
dura mater was integral and the orbital periosteum
was apparently free (Figure 1).
Year XII • No. 44 (3/2019)
Rezumat Bogdan Mocanu,
Silviu Oprescu
Prezentăm cazul unui pacient, în vârstă de 62 de ani, cu o Brain Institute –
formațiune tumorală voluminoasă de sinus frontal bilateral, Monza Hospital,
cu sindrom cefalalgic sever și distrucţia parcelară a laminei Bucharest, Romania
papiracee stângi și a peretelui posterior al sinusului frontal
drept. Abordul endoscopic s-a efectuat printr-o fereastră
intersprâncenoasă de mici dimensiuni, cu refacerea suportului
osos la finalul intervenției utilizând o plasă din titan. Deși
echipa chirurgicală are o experiență îndelungată în abordul
transnazal endoscopic, există cazuri în care parcursul trans­
nazal nu poate rezolva în deplină siguranță anumite pato­
lo­gii. Autorii doresc să sublinieze necesitatea utilizării unui
abord care să asigure managementul corespunzător al unor
eventuale complicații intraoperatorii specifice acestor tumori
(sângerări, fistulă de lichid cefalorahidian), iar în cazul de față
abordul endoscopic transcranian a reprezentat cea mai bună
soluție.
Cuvinte-cheie: sinus frontal, tumoră, abord endoscopic
extern
The apparent origin located at the posterior wall
of the bilateral frontal sinus, the partial exposure
of the dura mater and the destruction of the lamina
papyracea with the penetration of the tumor into the
left orbit led to the decision of an external endoscopic
approach. We considered that a possible cerebrospi-
nal fluid (CSF) leak at the posterior wall of the right
frontal sinus, as well as an important intraoperative
bleeding couldn’t be managed properly by a transna-
sal approach.
We underwent the surgery using general anesthe-
sia with OT intubation. Although the tumor was large
(horizontal diameter: 82 mm, antero-posterior: 18
mm, vertical: 43 mm), we decided that the approach
should be performed by the midline of the glabella,
through a bone window that would allow the access
of a telescope with a 4 mm diameter plus two other
tools (suction tube + endoscopic forceps or a 2-mm
microdebrider). Skin incision: 20 mm, bone fenes-
tration with 13 mm horizontal diameter and 10 mm
vertical diameter.
A hard tumor was shown upon palpation, with a
macroscopic aspect of an inverted papilloma, well-
vascularized, that occupied both frontal sinuses and
dived through the nasofrontal ducts in the anterior
7
rhinology

Figure 1. Up: CT and MRI T2 FSE axial preoperative. Down: partial destruction of the left eye lamina papyracea, bone breach
to anterior cerebral fossa

ethmoidal cells. The apparent origin of the tumor was
located at the junction between the posterior wall of
the left frontal sinus and the intersinusal septum, in
the upper floor of the sinus cavity.
Although the approach was carried out through a
small hole, using the 300, 700 and 900 angled optics
and the angled tools (Heuwieser forceps of 700 and
900, angled suction tube and a monopolar malleable
suction cautery), we achieved a full-macroscopic
abaltion using “piece-meal” method. There was a par-
tial exposure of the dura mater and the left orbital
periosteum, but there was no signs of penetration
at their level.
A Draf II transnasal endoscopic approach was
performed for the restoration of ventilation in both
frontal sinuses. Radiofrequency hemostasis – fulfu-
ration 10 W. Efficient hemostasis; did not require
nasal package. The integrity of the bone support was

8 Year XII • No. 44 (3/2019)

Figure 2. Intraoperative macroscopic aspect – 700 optics. Restoration of bone support using titanium mesh

Figure 3. Up: postoperative CT aspect – axial, sagital. Down: lenghts of bone brace – 13 mm/10 mm

Year XII • No. 44 (3/2019)

9
rhinology
restored using a titanium mesh fixed with biocom-
patible screws (Figure 2). Intradermal skin suture
(Vicryl 5.0).
A CT scan using a contrast substance was per-
formed at the end of the surgery (Figure 3). It con-
firmed the complete macroscopic resection of the
tumor and a wide ventilation of both frontal sinuses.
Although, macroscopically, the appearance sug-
gested an inverted papilloma, the IHC examination
of the resected piece described tissue fragments cov-
ered by a respiratory type epithelium, with edema-
like stroma with abundant chronic inflammatory
infiltrate adding eosinophils and normal-looking
glandular structures. IHC revealed the diagnosis of
a glandular subtype of sinus inflammatory polyp.
We presented this case to point out that there are
many situations when the pathology of the frontal si-
nuses still requires an external approach, even when
10
we consider that the surgical team has a strong expe-
rience in transnasal endoscopic surgery.
The peculiarity of the case was the small bone-
window through which the tumor was resected, the
advantage we had being given by the usage of optics
and angular tools that made the resection complete
and safe for the patient.
CSF leaks, the frontal sinus osteomas that exceed
the diameter of the nasofrontal duct and large solid
tumors can be safely managed for the patient through
a minimally invasive transcranial endoscopic ap-
proach that is lesion-centered. n
Note: This article does not contain any references, since
it describes a strictly personal experience of the authors.
Conflict of interests: The authors declare no
conflict of interests.
Reclamă ORL 44(3)0103
Year XII • No. 44 (3/2019)
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www.karlstorz.com
 rhinology
Frontal sinus osteoma –
case report
C. Drăgulescu, Abstract
M. Chițac,
A. Weisman, Osteomas are benign tumors of the paranasal sinuses,
and are mostly located in the frontal sinus. The evolution
M. Condrat, of the osteomas is slow and silent. The osteomas are often
X. Dolghii, discovered incidentally on a craniofacial CT scan. Due to
E. Onisâi, the slow growing nature of this tumour, the therapeutic
M. Vasilca approach is usually “watch and wait”. When symptoms
“Prof. Dr. Dorin Hociotă”
occur, the surgical approach is required. This can be
Institute of Phono-Audiology external, endoscopic or combined. The authors report the
and Functional ENT Surgery, case of a 55-year-old female patient who was admitted to
Bucharest, Romania
the hospital with a history of progressive frontal headache
for 12 months. The clinical ENT examination and the
paralinical exams (nasal endoscopy, computed tomography
– head, paranasal sinuses) were suggestive for a left
frontal sinus osteoma. The surgical management of the
osteoma was a combined approach, including the external
Ogston-Luc technique and the endoscopic approach. The
postoperative period was uneventful, with no complications,
and the drain tube was removed 14 days after surgery.
Keywords: osteoma, frontal sinus, combined surgical
approach
Submission date:
14.08.2019 Osteomul frontal – caz clinic
Acceptance date: Suggested citation for this article: Drăgulescu C, Chițac M, Weisman A, Condrat M, Dolghii X, Onisâi E, Vasilca M. Frontal sinus osteoma – case report.
31.08.2019 ORL.ro. 2019;44(3):12-15.
Case report
We present the case of a female patient, 55 years
old, who was admitted to the hospital with complaints
of frontal headache and minor left nasal obstruction
for one year. The clinical and endoscopic ENT exami-
nations (pain of the frontal left sinus pressure point,
clear nasal fossae), as well as paraclinical examina-
tions (native computed tomography of the paranasal
sinuses – Figure 1) showed an extensive, hyperdense,
round-ovalar, sessile tumor of the left frontal sinus,
of approximately 20/12 mm, with attachment on its
anterior wall, expanding through the frontal sinus
cavity.
The clinical and paraclinical examinations revealed
a voluminous left frontal sinus osteoma. After ac-
curate preoperative preparations, surgery was per-
formed (Figures 2, 3, 4 and 5) using a combined sur-
gical approach: external (Ogston-Luc technique) and
endoscopic. We made an arcuate over-brow incision
in the medial half of the eyebrow arch, followed by
tegument, muscle and periosteum surgical dissection.
We performed the trephination of the anterior wall of
the left frontal sinus, uncovering the tumoral growth
12
Rezumat
Osteomul reprezintă o tumoră benignă a sinusurilor para­
na­zale, afectând cu predilecție sinusul frontal. Are o evoluție
lentă și silențioasă, fiind descoperit adesea accidental prin
examenul CT efectuat pentru diagnosticul altor patologii
rinosinuzale. Atitudinea terapeutică uzuală este „watch and
wait”, dar în momentul în care osteomul devine simp­to­
ma­­tic, tratamentul de elecție este chirurgical, prin tehnici
en­­do­­sco­­pice clasice sau prin abord mixt. Lucrarea prezintă
ca­zul unei paciente în vârstă de 55 de ani care se internează
în spi­tal pentru cefalee frontală cronică progresivă debutată
în urmă cu aproximativ un an. Examinările clinice și para­
cli­ni­ce (examinare endoscopică, examen computer-tomo­
gra­fic cranio-cerebral) ridică suspiciunea unui osteom de
si­nus fron­­tal stâng. Conduita terapeutică de elecție este cea
chi­­rur­­gi­ca­lă, prin abord mixt, extern (de tip Ogston-Luc) și
en­­do­­scopic. Evoluția postoperatorie a fost favorabilă, fără
com­pli­ca­ţii, tubul de drenaj fiind înlăturat la 14 zile de la
operaţie.
Cuvinte-cheie: osteom, sinus frontal, abord chirurgical
mixt
inside the sinus. The tumor was white and had a hard-
bone consistency, emerging from the anterior wall of
the left frontal sinus. Tumor excision was then per-
formed and the specimen was sent for histopathologi-
cal examination. Under endoscopic control, a passive
drainage tube was mounted in the nasofrontal canal.
The tube was then attached to the vestibulum nasi
with a suture thread. The left frontal sinus cavity was
filled with hemostatic sponge, then we restored the
tissue alignment and did the wound dressing.
The histopathologic examination confirmed the
diagnosis of left frontal sinus osteoma.
The postoperative evolution was favorable. The
patient received i.v. broad-spectrum antibiotics,
NSAIDs, analgesic treatment, gastric protection and
nasal decongestants. Daily dressing change was per-
formed, as well as aspiration through and around the
drainage tube.
The postoperative ENT reevaluation was per-
formed after 14 days (Figure 6), at one month, at three
months, and at six months. The patient’s post-surgical
evolution was uneventful, without any immediate or
long-term complications.
Year XII • No. 44 (3/2019)
 Figure 1. Head CT – paranasal sinuses slices

Discussion
Osteoma is the most common tumor of paranasal
sinuses, often with a slow and silent evolution. The
most frequently involved site is frontal sinus, followed
by ethmoid and maxilar sinuses. The sphenoid sinus
is rarely involved(1,2). Males are slightly more often
affected by this disease than females (M:F ratio =
1.3:1)(3).
In general, the dimension of osteomas may vary
between 2 and 30 mm. Osteomas bigger than 30 mm
or the ones weighing more than 110 g are considered
to be giant(4).
The etiology of osteomas is still unknown. Sev-
eral hypotheses have been taken into consideration:
traumatic or infectious triggers, calcium metabolism
disorders, or embryonic malformations(5).
Frontal sinus osteoma grading system(6) Figure 2. Intraoperative aspect
Grade I. The base of attachment is posterior-in-
ferior along the frontal recess. The tumor is medial
to a virtual sagittal plane through the lamina papy-
racea. The anterior-posterior diameter of the lesion
is <75% of the anterior-posterior dimension of the
frontal recess.
Grade II. The base of attachment is posterior-in-
ferior along the frontal recess. The tumor is medial
to a virtual sagittal plane through the lamina papy-
racea. The anterior-posterior diameter of the lesion
is >75% of the anterior-posterior dimension of the
frontal recess.
Grade III. The base of attachment is anterior or
superiorly located within the frontal sinus and/or
the tumor extends lateral to a virtual sagittal plane
through the lamina papyracea.
Grade IV. Tumor fills the entire frontal sinus (the
current case).
Osteomas are white, hard, well circumscribed,
round or oval, sesile (rarely pediculated), bosselated
tumors. Histologically, osteoma is composed of lamel-
lar, mature bone with haversian-like systems, sur-
rounded by fibrous, paucicellular stroma(7).
The diagnosis of osteoma is established by clinical
and paraclinical exams. The patients may complain of
persistent frontal pain unresponsive to analgesic or Figure 3. Intraoperative aspect

Year XII • No. 44 (3/2019)

13
rhinology
Figure 4. Frontal recess
antiinflammatory medication, hemifacial pain, rhino-
reea and nasal obstruction. If the growth of osteoma
is also intraorbital, proptosis and/or diplopia may oc-
cur. Computed tomography of the head and paranasal
sinuses is the gold standard for the diagnosis of oste­
oma and is also necessary for its management. MRI is
useful when intracranial extensions are suspected(8).
The differential diagnosis (9) of frontal sinus os-
teoma includes: acute suppurative frontal sinusitis
or exacerbated chronic frontal sinusitis, other rhinosi-
nusal benign tumors (mucocele, adenoma, papilloma,
myxoma, glyoma, inverted papilloma, antrochoanal
polyp, dermoid cyst), malignant tumors of frontal
sinus (osteosarcoma, meningoencephalocele, Gardner
syndrome, orbital/retroorbital tumors).
Being mostly asymptomatic, frontal sinus osteomas
grow and extend slowly, being able to cause various
neurological and/or ophtalmological complications(10):
CSF fistula, meningitis, epidural abcess, subdural
empyema, cerebral abcess, cranial nerves paralysis,
orbital celullitis, orbitar abcess, optic neuritis.
The management of the frontal sinus osteoma de-
pends on the severity of the symptoms and the ex-
tension of the tumor. If the osteoma is discovered
incidentally, being small sized and with a slow and
Figure 6. ENT reevaluation at 14 days after surgery
14
Figure 5. Drainage tube through the frontal recess
silent evolution, then usually the “watch and wait”
approach is preferred(11). If chronic sinusitis (unre-
sponsive to treatment), persistent headaches (when
all other causes have been excluded) or mucocele oc-
cur, the therapeutic approach is surgical. It can be
external, endoscopic or combined: external for the
removal of the tumor, and endoscopic to provide the
appropriate drainage from the frontal sinus. The ap-
proach depends mostly on the site and dimension
of the osteoma. Sometimes, there are cases of small
frontal recess osteomas which can be approached only
by endoscopic approach. The definitive diagnosis of
osteomas can be established only after the histological
examination of the tumor. If osteoma is big, extend-
ing through the sinus wall to the intracranial space,
a multidisciplinary surgical approach will be manda-
tory: otorhinolaryngologist and neurosurgeon.
The postoperative complications which may occur
are: subcutaneous emphysema, persistent suppura-
tive sinusitis, fistulization, frontal osteomyelitis,
supraorbitar nerve branches damage, supraorbitar
neuralgia, ecchymosis, palpebral edema, dyplopia,
epiphora, frontal recess stenosis, recurrence of frontal
sinusitis, and tumoral recurrence.
Conclusions
Although osteomas of paransal sinuses are benign
tumors, with a slow and silent growth, they need to be
diagnosed in time and followed-up for the establishment
of the proper therapeutic approach, depending on the
symptoms and/or the complications that may appear.
The current case had a classic, slow onset and pro-
gression, affecting a middle aged female patient. The
symtoms have occured gradually: progressive headache
started 12 months before the admission to the hospital.
The presumptive diagnosis was established after clinical
and paraclinical examinations (transnasal endoscopy,
native computed tomography of the head and paranasal
sinuses). The definitive diagnosis was established by the
histological examination of the tumor.
Year XII • No. 44 (3/2019)
 Considering the size of the tumor (4 th grade, tak-
ing into consideration the classification of osteo-
mas mentioned above), the decision regarding the
therapeutic approach was taken and the combined
approach surgery was performed: external and en-
doscopic, which allowed the ablation of the tumor,
as well as proper postoperative drainage of frontal
sinus.
1. Celenk F, Baysal E, Karata ZA, Durucu C, Mumbuc S, Kanlikam M. Paranasal sinus
References
osteomas. J Craniofac Surg. 2012; 23:e433–7.
2. Georgalas C, Goudakos J, Fokkens WJ. Osteoma of the skull base and sinuses.
Otolaryngol Clin North Am. 2011; 44:875– 90.
3. Savastano M, et al. Head and Neck Medicine and Surgery. American Journal of
Otolaryngology. 2007; 28: 427–429.
4. Izci Y. Management of the large cranial osteoma: experience with 13 adult
patients. Acta Neurochir (Wien). 2005 Nov; 147(11):1151-5; discussion 1155.
5. Cokkeser Y, Bayarogullari H, Kahraman SS. Our experience with the surgical
management of paranasal sinuses osteomas. Eur Arch Otorhinolaryngol. 2013;
270:123–8.
6. Chiu AG, Schipor I, Cohen NA, Kennedy DW, Palmer JN. Surgical Decisions in the
Management of Frontal Sinus Osteomas. American Journal of Rhinology. 2005;
Year XII • No. 44 (3/2019)
Due to the early diagnosis of the osteoma, no com-
plications have been noticed, the evolution being fa-
vorable. ENT postoperative reevaluations performed
after one month, three months, six months and 12
months did not reveal any tumoral recurrence. n
Conflict of interests: The authors declare no
conflict of interests.
19(2), 191–197.
7. Nielse GP, Rosenberg AE. Update on Bone Forming Tumors of the Head and
Neck. Head Neck Pathol. 2007 Sep; 1(1): 87–93.
8. Castelnuovo P, Valentini V, Giovannetti F, Bignami M, Cassoni A, Iannetti G.
Osteomas of the Maxillofacial District. Journal of Craniofacial Surgery. 2008; 19(6),
1446–1452.
9. Bacalbașa A. Cazuri rare în otorinolaringologie, Ed. Medic Art, Bucureşti, 2006.
10. Turan Ş, Kaya E, Pınarbaşlı MÖ, Çaklı H. The Analysis of Patients Operated for
Frontal Sinus Osteomas. Turk Arch Otorhinolaryngol. 2015 Dec; 53(4): 144–149.
11. Turri-Zanoni M, Dallan I, Terranova P, Battaglia P, Karligkiotis A, Bignami M,
Castelnuovo P. Frontoethmoidal and intraorbital osteomas: exploring the
limits of the endoscopic approach. Arch Otolaryngol Head Neck Surg. 2012 May;
138(5):498-504.
15
 rhinology
Carcinoma of the nasal
vestibule – comments
on a clinical case
Mihail Tuşaliu1,2, Abstract
Lavinia-Georgiana
Ilinca1, With an incidence of less than 1% of all head and neck
neoplasia, basal cell carcinoma located in the nasal
Iulia Tiţă1 vestibule is a rare pathology in daily ENT practice,
1. “Prof. Dr. Dorin Hociotă” characterized by a nonspecific symptomatology. Surgery
Institute of Phonoaudiology
and ENT Functional Surgery, and radiotherapy are currently the most commonly used
Bucharest means to address it, however there is no generally agreed
2. “Carol Davila” University gold standard. The challenge that is posed then lies in
of Medicine and Pharmacy, performing a full surgical resection of the tumor mass
Bucharest
while, at the same time, obtaining an aesthetically and
functionally suitable outcome. The authors of this paper
give an account of the clinical and therapeutic management
particularities involved in the case of a 52-year-old patient
with basal-cell carcinoma in the right nasal vestibule.
Keywords: nasal vestibular carcinoma, surgical treatment
Submission date:
10.08.2019 Carcinomul de vestibul nazal – comentarii pe baza unui caz clinic
Acceptance date: Suggested citation for this article: Tuşaliu M, Ilinca LG, Tiţă I. Carcinoma of the nasal vestibule – comments on a clinical case. ORL.ro. 2019;44(3):16-19.
28.08.2019
Introduction
Malignant tumors of the nose and paranasal si-
nuses account for 3% of the head and neck neoplasia.
They occur more commonly in men, with a male-to-
female ratio of 3:2, irrespective of location or histo-
logical types involved(1). Among these pathologies, less
than 1% are nasal vestibule malignant tumors(2). Due
to the anatomical features of the nasal vestibule, it
could be argued that nasal vestibule tumors constitute
a particular kind of pathology. Cone-shaped, with a
maximum diameter of 1.5-2 cm, the nasal vestibule
space lies between the nose wings, laterally, and the
nasal septum, medially, being separated from the
nasal cavity by limen nasi. Limen nasi serves as the
junction between skin and the mucosa. It is lined with
skin and contains sebaceous glands, sweat glands and
hair follicles.
Among nasal vestibule tumors, well differentiated
squamous cell carcinoma and moderately differentiated
squamous cell carcinoma are the most frequently occur-
ring histological types, with other commonly observed
types being basal cell carcinoma and melanoma(2,3). Nasal
vestibule neoplasia could be likened to skin neoplasia,
progressing differently and having a better outlook than
those of the nasal cavity or paranasal sinuses(2).
16
Rezumat
Întâlnit la mai puțin de 1% din totalitatea neoplasmelor
capului și gâtului, carcinomul cu localizare la nivelul ves­ti­bu­
lului nazal este o patologie rară în practica ORL, cu un ta­blou
clinic nespecific. Mijloacele terapeutice cel mai frecvent uti­li­
za­te sunt chirurgia și radioterapia, însă nu există un con­sens în
ceea ce privește tratamentul de elecție. Provocarea în această
patologie este reprezentată de reușita unei rezecții tumorale
complete cu limite de siguranță și cu obținerea în același
timp a unui rezultat estetic și funcțional convenabil. Autorii
prezintă particularitățile clinice și managementul terapeutic
în cazul unui pacient în vârstă de 52 de ani cu carcinom
bazocelular de vestibul nazal drept.
Cuvinte-cheie: carcinom vestibul nazal, tratament
chirurgical
From a clinical standpoint, the main symptoms of
most tumors occurring in the nasal cavity, sinuses and
the nasal vestibule are unilateral obstruction, unilateral
recurrent nosebleeds or, in the case of nasal vestibule
tumors, an asymmetrically shaped nasal pyramid and
localized swelling. About 6% of all cases also exhibit
metastatic adenopathy. These, when present, consti-
tute a negatively impacting factor on the overall patient
prognosis(3).
A CT scan allows for a full assessment of the entire
tumor mass, as well as evaluating the extent to which
it may affect neighbouring structures. This, in turn,
can be followed by an MRI scan in order to highlight
the degree the tumor has spread to the nearby soft
tissues.
The available treatment options include surgical re-
section, radiotherapy and chemotherapy. Surgery is of-
ten followed by undesirable aesthetic outcomes, which
is why some authors recommend radiotherapy as a first
course of action, with surgery only considered upon the
failure of the former(1). At the same time, studies find
similar results achieved through surgery, which has the
added benefit of providing greater local control. Follow-
up reconstructive procedures could mitigate some of the
potential downsides(3,4).
Year XII • No. 44 (3/2019)
 Figure 1. Tumor mass inside the right nasal vestibule,
extending into the anterior 1/3 of the nasal fossa
According to the American Joint Committee on
Cancer (AJCC), nasal vestibule tumors can be classified
in four stages: T1 – primary tumors with a maximum
diameter of 2 cm, T2 – tumors larger than 2 cm, but
not exceeding 5 cm at their maximum diameter, T3 –
tumors with a maximum diameter greater than 5 cm,
and T4 – tumors extending to cartilages, bone or nerve
structures(1). After reviewing this classification, Wang
divided malignant nasal vestibule tumors into three
stages, as follows: T1 – lesions limited to the nasal ves-
tibule, relatively superficial, T2 – lesions extended to
adjacent structures such as the nasal septum, upper lip,
outer layer of the nasal pyramid and/or the nasolabial
fold, without extending to the underlying bone, and T3 –
lesions extending up to the hard palate, nasal turbinates
Figure 3. Intraoperative aspect
Year XII • No. 44 (3/2019)
Figure 2. CT scan of the tumor mass
and/or paranasal sinuses, extending to nearby muscle
and bone structures(4).
Case report
The authors of this paper give an account of a clini-
cal case of a 52-year-old patient, with no significant
personal pathological history, who showed up at our
clinic exhibiting a tumor mass located in the right nasal
vestibule, accusing chronic obstruction and recurrent
anterior nosebleeds in the right nostril, symptoms he
had experienced for about a year prior.
The ENT clinical examination and nasal endoscopy
that have been performed revealed asymmetrical nos-
trils (right larger than the left one), swelling on the right
side of the nasal pyramid, tensed dorsum nasi and right
17
rhinology
Figure 4. Excised tumor mass
nasal wing caused by the presence of a protruding, sore
tumor mass, bleeding upon examinations and occupying
the lateral and upper part of the right nasal vestibule
and the anterior part of the right nasal fossa (Figure 1).
A CT scan revealed a nodular tumor mass developing
in the right nasal vestibule, 22/32 mm wide and 19 mm
long, irregular in shape and tissue density, with partial
bone lysis in the right nasal bone and septum and moder-
ate deformity of the right nasal wing (Figure 2).
Considering all available clinical and paraclinical
data, surgery was chosen as the preferred course of ac-
tion, with the aim of performing a resection and a biopsy
of the tumor mass. With the patient undergoing general
anaesthesia and orotracheal intubation, an arched in-
cision was made on the lateral wall of the right nasal
vestibule. The process of detaching the tumor was hin-
dered by the tumor mass extending towards the lateral
pole of the right alar cartilage and the right triangular
cartilage, coming into contact with the septal mucosa
and the underlying cartilage from the anterior 1/3 of
the anterior half of the nasal septum (Figure 3).
A one-piece resection was performed, removing the tu-
moral mass, together with the alar cartilage, triangular
cartilage, mucosa and septal cartilage. The mass appeared
Figure 5. Postsurgical aspect
18
to have a hard, fibrous consistency in the lateral half, while
being soft, bleeding, with areas of necrosis in its medial
part. At a macroscopic level, the right nasal bone was estab-
lished to be the upper extent of the tumor, while the right
middle nasal turbinate constituted the posterior boundary.
Biopsy samples were collected from the upper, medial and
lateral tumoral poles, for maximal safety margins. A frag-
ment of the quadrilateral cartilage was used in place of the
triangular cartilage, on the inner, upper side of the nasal
dorsum, and secured by transfixing wire. The excised mass
was sent to the pathological anatomy laboratory, pending
histopathological diagnosis. According to Wang’s classifica-
tion, the mass corresponds to stage T2 (Figure 4).
The histopathological diagnosis, as confirmed by per-
forming immunohistochemical tests, was established to
be moderately differentiated basal cell carcinoma, G2.
The biopsy samples collected from the septal cartilage
and mucosa of the upper half of the anterior 1/3 of the
nasal septum, as well as the samples collected from the
upper and lateral tumor poles as maximal safety margins
showed a typical histological appearance.
Following these steps, the patient was referred to a
specialized oncological committee. The committee then
advised performing an MRI scan to provide a better
overall post-surgery assessment without causing bud
lesions, with increased contrast uptake in the mucosa
and the right infraorbital nerve, as these constitute
common post-therapeutic inflammatory changes. The
patient was then discharged without pursuing further
specialized oncological treatment.
Subsequent follow-up post-surgery check-ups did not
find so far macroscopic signs of any potential leftover
tumor residue. Aesthetically, the outcome of the inter-
vention is satisfactory, in spite of the patient developing
a small clogging area on the right nasal wing. Function-
ally, the outcome could be said to be a suitable one, as
the patient managed to retain functionality of the right
nostril respiratory pathways (Figure 5).
Discussion
Accounting for less than 1% of all head and neck tu-
mors, malignant nasal vestibule tumors constitute a
Year XII • No. 44 (3/2019)
rare pathology. Nasal vestibule neoplasia mostly occurs
in men, who make up around 55-70% of all cases, with
an average age between 60 to 70 years old(2). Malignant
nasal vestibule tumors include the following: squamous
epidermal carcinoma, this being the most common his-
tological type, basal cell epidermal carcinoma, undif-
ferentiated carcinoma, glandular carcinoma, sarcomas,
melanomas, and salivary malignancies (cylindroma)(1).
As mentioned in the literature, prolonged sun exposure
and smoking constitute increased nasal vestibular neo-
plasia risk factors. However, the precise nature of the re-
lation between these factors and nasal vestibular cancer
is not fully understood, literature data being insufficient
due to a limited number of reported cases(2).
The symptomatology characteristic of the early stages
of these tumors is nonspecific, being broadly defined by
unilateral nasal obstruction, with the tumors extend-
ing to neighbouring structures as they progress, caus-
ing nosebleeds and/or facial deformities. Several studies
cite the presence of metastatic adenopathy at the time of
diagnosis and the localization of the tumor in the nasal
septum as factors with a negative impact over the outlook,
both in terms of patient survival, as well as of potential
tumor regrowth(3,4). The existing nasal vestibular tumor
classifications, as described in the literature, are not uni-
versally agreed upon and, so far, their accuracy has not
been definitively proven. Moreover, there’s a diversity
of views in regards to dealing with early stage tumors.
Some authors recommend radiotherapy for likely yield-
ing better outcomes, aesthetically, while others advocate
pursuing a surgical intervention regardless of the tumor’s
stage to ensure greater safety, whether or not pursued in
conjunction with subsequent radiotherapy(1,4,5). There is,
therefore, no standardized course of action for address-
ing these vestibular malignancies and a certain degree of
controversy remains, both because of the rarity of these
tumors, as well as due to their histological diversity, hard
to reach location and extent.
In the case study detailed in this account, the authors
opted for the surgical removal of the tumor mass and
have done so using a mixed endonasal and endoscopic
approach, allowing for greater surgical control. An ele-
ment worthy of consideration is that multiple biopsy
samples were collected during the intervention from
the upper, medial and lateral poles of the tumor mass, in
order to more accurately establish follow-up steps. Work-
ing within the anatomical constraints of the narrow
nasal vestibule space, a one-piece resection was carried
out, successfully removing the entire macroscopic area
encompassed by the tumor mass. All biopsy samples
collected turned out to be negative. In cases such as the
one detailed in this paper, successful one-piece resec-
tions of the tumor mass, together with negative tumor
safety margins biopsy results are decisive factors in the
patient’s medium- and long-term prognosis.
After the histopathological diagnosis was confirmed
through immunohistochemical examination, the patient
was referred to a specialist oncological committee. After
surgery, an MRI examination was carried out, the result
Year XII • No. 44 (3/2019)
of which did not reveal the presence of any potential
leftover tumor residue. It was subsequently decided not
to pursue any specific oncological treatment in this case,
while continuing to actively monitor the patient.
Aesthetic and functional considerations regarding
nasal vestibular surgery pose an added layer of diffi-
culty. Since the tumor mass extended to the alar and
triangular cartilages, a one-piece resection of the tumor
mass and the two cartilages was the preferred course of
action pursued. In order to address negative aesthetic
considerations arising as a result of the intervention, an
autograft created from a fragment of the quadrilateral
cartilage was used in place of the triangular cartilage on
the inner, upper side of the nasal dorsum, being secured
in place by transfixing wire. Aesthetically, the outcome
of the procedure is suitable, the patient exhibiting only
minimal clogging of the right nasal wing. Currently, there
are differences of opinion between practitioners on how
to approach aesthetic considerations. While some authors
favor specialized oncological treatment, others advocate
for the greater safety provided by the full tumor resec-
tions, with subsequent reconstructive interventions car-
ried out at a later stage, in a different procedure.
With the tumor mass being located in the internal na-
sal valve and extending to the anterior half of the right
nasal fossa, the alar and triangular cartilage, resection
proved challenging. The postoperative healing process
was tedious, with multiple flanges and granulation tis-
sue being formed, while adhesions had to be periodically
removed. However, the careful management of the heal-
ing process resulted in a suitable, functional outcome,
as the patient regained functionality of the right nostril
respiratory pathways.
Conclusions
Malignant nasal vestibule tumors constitute a par-
ticular, rare pathology, accounting for less than 1% of
all head and neck tumors. The difficulty in reaching the
location and the extent of the tumor can pose a challenge
for ENT practitioners. One-piece tumor resection, as well
as the resection margins biopsy samples testing negative
are important and decisive factors for the patient’s prog-
nosis, increasing the patient’s chances of medium- and
long-term survival. n
Reclamă ORL 44(3)2005
Conflict of interests: The authors declare no
conflict of interests.
References
1. Daele JJ, Vander Poorten V, Rombaux P, Hamoir M. Cancer of the nasal vestibule,
nasal cavity and paranasal sinuses. B-ENT. 2005; 1(1): 87-96.
2. Dagan R, Amdur RJ, Dziegielewski PT. Cancer of the nasal vestibule, Feb 2019,
Reclamă ORL 44(3)0604
available at www.uptodate.com.
3. Taxy JB. Squamous Carcinoma of the Nasal Vestibule - An Analysis of Five Cases
and Literature Review. American Journal of Clinical Pathology. 1997; 107 (6): 698-
703.
4. Horsmans JDJ, Godballe C, Jørgensen KE, Bastholt L, Løntoft E. Squamous cell
carcinoma of the nasal vestibule. The Journal of Laryngology & Otology. 1999; 37:
117-121.
5. Ledderose GJ, Reu S, Englhard AS, Krause E. Endonasal resection of early
stage squamous cell carcinoma of the nasal vestibule. European Archives of
Otorhinolaryngology. 2014; 271(5): 1051-1055.
19
 Noile ghiduri internaţionale
privind rinita alergică se axează
pe nevoile și comportamentul real
al pacientului
Managementul actual al rinitei alergice (RA) nu lua în con­si­de­rare, pe deplin, până
de curând, nevoile pacientului. Pacienții își doresc o ameliorare rapidă și eficientă
a simptomelor, nu doresc să ia medicație pe termen lung, conform recomandărilor
pe care le primesc, având tendința de a utiliza tratamentul doar la nevoie și,
deseori, folosesc 3-4 medicamente, în în­cer­carea de a-și trata eficient simptomele.
Cu toate acestea, mulți pacienți nu au un tratament eficient, iar simptomele lor nu
sunt controlate.

Noile recomandări ale ghidului ARIA(1) și ale ghidului de tra-
tament al RA sezoniere (US Practice Parameters)(2) subliniază
consistent includerea nevoilor și preferințelor pacientului în
luarea deciziei terapeutice și re­co­mandă combinația azelas-
tină/fluticazonă cu administrare intranazală ca primă linie
de tratament. Dymista® (azelastină/fluticazonă propionat)
spray nazal are un debut rapid al ac­țiu­nii, la numai 5 minute
de la administrare(3), și este mai eficient decât medicamentele
disponibile în prezent, inclusiv corticosteroizii intranazali(4,5,14).
Dymista® reduce nevoia de a utiliza medicamente asociate pen-
tru RA(15) și oferă un control al simptomelor cu 6 zile mai rapid
față de alte medicamente cu administrare intranazală(6,14,15).
Implicațiile pentru practica medicală zilnică
Majoritatea pacienților care se prezintă la cabinetul medi-
cului manifestă simptome de rinită alergică moderate până
Figura 1. Procentul de pacienți cu RA ușoară (n = 254) sau
moderată/severă (n = 746) cu un punctaj de 2 (moderată) sau
3 (severă) la evaluările simptomelor nazale și oculare în ziua
evaluării
la severe(7,8) și au încercat deja mai multe medicamente, cu
beneficii variabile, dar cel mai adesea limitate (figura 1).
Studiile clinice randomizate, controlate, precum și cele
derulate cu pacienți din viața reală(16) au indicat faptul că
Dymista® este mai eficient decât monoterapia cu CSIN sau
antihistaminice(4,16) și are potențialul de a opri cercul vicios
al nerespectării tratamentului, utilizării medicației asociate
și controlului inadecvat al simptomelor. Costurile totale ale
Dymista® ar putea fi mai reduse față de cele ale altor medi-
camente, având în vedere capacitatea acestuia de a oferi un
control mai rapid al simptomelor, reducând astfel medicația
asociată(6,15).
De-a lungul anilor, societățile profesionale și autoritățile
de reglementare au susținut cu precădere parametrii de efi-
cacitate care nu iau în considerare comportamentul și nevoile
pacienților cu RA. Farmacoterapia RA trebuie să își demon-
streze eficacitatea în decurs de 14 zile pentru simptomele
majore precum strănutul, pruritul, congestia nazală și rino-
reea, în comparație cu placebo și cu medicamentele compa-
ratoare. Pacienții care respectă tratamentul (≥70% zile) sunt
singurii ale căror rezultate pot fi analizate. Autoritățile de
reglementare și societățile profesionale pornesc de la premisa
că pacienții se conformează și își administrează aceste me-
dicamente conform recomandărilor, pentru o perioadă mai
lungă. Cu toate acestea, evidențele din viața reală obținute
cu ajutorul unei aplicații digitale indică faptul că pacienții nu
respectă recomandările sau prescripțiile medicale și folosesc
automedicația intermitent, când nu se simt bine(5,9).
Sunt disponibile o serie de studii și sondaje în rândul
pacienților, iar acestea subliniază faptul că pacienții își doresc
o ameliorare rapidă și eficientă a simptomelor, schimbân­
du-și medicația în mod frecvent când acestea nu sunt con-
trolate(8,10). Prin urmare, ghidurile medicale și criteriile de
eficacitate actuale nu reflectă situația din viața reală și nevoile
pacientului.
Aplicația MASK-air®, o platformă digitală centrată pe bunele
practici de îngrijire a pacienților, integrată(11), ia în considerare
tratamentul rinitei alergice de la automedicație până la reco-
mandările farmacistului și ale medicului, nevoile pacienților și
comportamentul acestora. Instrumentul este o aplicație care
evaluează simptomele RA, cu ajutorul scalei vizuale analogice,
productivitatea muncii și tratamentul pacienților.
Un studiu observațional, care include peste 6000 de pa­
cienți utilizatori ai acestei aplicații, a indicat că puțin pes-
te 11% dintre pacienți sunt aderenți la tratament(9). Mulți
pacienți folosesc 3 sau 4 medicamente contra rinitei alergice,
în încercarea de a-și trata eficient simptomele(5). Se poate trage
Figura 2. Efectul Dymista® asupra simptomelor RA, evaluate
concluzia că ghidurile și studiile actuale nu iau în calcul rea- prin scorul scalei vizuale analogice (VAS) (n=2656)
litatea și nevoile pacienților.
Prof. Bousqet împreună cu alți experți precum prof. Ca-
nonica, fostul președinte al Organizației Mondiale pentru
Alergie (The World Allergy Organization), au actualizat re-
comandările ghidului ARIA și au inclus nevoile și comporta-
mentele reale ale pacienților. Debutul acțiunii și capacitatea
de a oferi controlul simptomelor atât în cadrul studiilor clinice
controlate, cât și în condiții de viață reală sunt parametri
importanți în evaluarea utilității medicamentelor actuale
pentru tratamentul RA.
Corticosteroizii intranazali și combinația în doză fixă aze-
lastină/fluticazonă propionat (Dymista®) sunt mai eficiente
față de medicamentele antihistaminice H1 cu administrare
orală(2,12). Antihistaminicele H1 cu administrare orală asociate
CSIN nu par să ofere beneficii suplimentare față de monote-
rapia cu CSIN(2). Dymista® s-a dovedit în studii clinice contro-
late, randomizate(2,4), precum și în studii în viața reală(5,6,13), a Figura 3. Modificarea scorului TNSS (0-12 h) față de valoarea
fi mai eficace decât CSIN. S-a demonstrat că Dymista® oferă inițială pe parcursul a 4 ore după administrare (FP: propionat
de fluticazonă; LOR: loratadină)
controlul simptomelor în viața reală (VAS <5) în numai 3 zile

016_09_09-19_LB-Dymi-RO
de la inițierea terapiei (figura 2)(16).
Dymista® are un debut al acțiunii la numai 5 minute de la Combinația în doză fixă de azelastină/fluticazonă (Dymis-
administrare și oferă pacienților o ameliorare rapidă și efici- ta®) cu administrare intranazală are caracteristicile unui
entă a simptomelor (figura 3)(3). medicament care, la pacienții cu rinită alergică moderată/
Corticosteroizii intranazali au nevoie de zile pentru a-și in- severă, poate opri cercul vicios al controlului inadecvat al
stala beneficiile terapeutice maxime și pot fi luați în considerare simptomelor și al utilizării medicamentelor asociate. Acest
numai pentru pacienții care își administrează regulat medi- fapt a fost luat în considerare, de asemenea, în noile ghiduri
camentul pe o perioadă lungă, situație care este foarte rară(3). internaționale. n

1. Brozek JL et al. Allergic Rhinitis and its Impact on Asthma (ARIA) Guidelines - 2016 Revision. Study. Clin Exp Allergy. 2019;49(4):442-60.
Bibliografie

J Allergy Clin Immunol. 2017;140(4):950-8.
2. Dykewicz MS et al. Treatment of seasonal allergic rhinitis: An evidence-based focused 2017
guideline update. Ann Allergy Asthma Immunol. 2017;119(6):489-511.
3. Bousquet J et al. Onset of Action of the Fixed Combination Intranasal Azelastine-Fluticasone
Propionate in an Allergen Exposure Chamber. J Allergy Clin Immunol Pract. 2018;6(5):1726-32.
4. Hampel FC et al. Double-blind, placebo-controlled study of azelastine and fluticasone in a single
nasal spray delivery device. Ann Allergy Asthma Immunol. 2010;105(2):168-73.
5. Bousquet J et al. Treatment of allergic rhinitis using mobile technology with real-world data: The
MASK observational pilot study. Allergy. 2018;73(9):1763-74.
6. Bedard A et al. Mobile technology offers novel insights on control and treatment of allergic
rhinitis. The Mask study. J. Allergy Clin Immunol. 2019 Apr. 2.
7. Bousquet J et al. Severity and impairment of allergic rhinitis in patients consulting in primary care.
J Allergy Clin Immunol. 2006;117(1):158-62.
8. Price D et al. The hidden burden of adult allergic rhinitis: UK healthcare resource utilisation survey.
Clin Transl Allergy. 2015;5:39.
9. Menditto E et al. Adherence to treatment in allergic rhinitis using mobile technology. The MASK
10. Valovirta E et al. The voice of the patients: allergic rhinitis is not a trivial disease. Curr Opin Allergy
Clin Immunol. 2008;8(1):1-9.
11. Bousquet J et al. Guidance to 2018 good practice: ARIA digitally-enabled, integrated, person-
centred care for rhinitis and asthma. Clin Transl Allergy. 2019;9:16.
12. Brozek JL et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy
Clin Immunol. 2010;126(3):466-76.
13. Bousquet J et al. MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis
and asthma multimorbidity using real-world-evidence. Clin Transl Allergy. 2018;8:45.
14. Meltzer E et al. Clinically relevant effect of a new intranasal therapy (MP29-02) in allergic rhinitis
assessed by responder analysis. Int. Arch. Allergy Immunol. 2013; 161:369-77.
15. Harrow B et al. A comparison of health care resource utilization and costs for patients with allergic
rhinitis on single-product or free-combination therapy of intranasal steroids and intranasal
anthistamines. J Manag Care Spec Pharm, 2016 Dec;22(12):1426-1436.
16. Klimek L et al. MP-AzeFlu provides rapid and effective allergic rhinitis control in real life: A pan-
European study. Allergy Asthma Proc. 2016: 37(5); 376-386(11).

Material promoțional destinat profesioniștilor din domeniul sănătății. Acest medicament se eliberează pe bază de prescripție medicală PRF.
Rezumatul caracteristicilor produsului poate fi accesat la www.anm.ro, secțiunea „Nomenclatorul medicamentelor de uz uman”.
Pentru raportarea evenimentelor adverse vă rugăm să vă adresați la tel.: 0372 579 004; fax: 0371 600 328; e-mail: pv.romania@mylan.com
Floreasca Business Park, Calea Floreasca 169A, Corp B, Parter, cod poștal 014459, sector 1, București, Telefon: 0372 579 000; Fax: 0371 600 326
Informații de prescriere. Denumirea comercială a medicamentului: Dymista 137 micrograme/50 micrograme/doză spray nazal suspensie. Compoziția calitativă și
cantitativă: Fiecare gram de suspensie conţine clorhidrat de azelastină 1000 micrograme şi propionat de fluticazonă 365 micrograme. O acţionare (doză de 0,14 g) eliberează
clorhidrat de azelastină 137 micrograme (= 125 micrograme de azelastină) şi propionat de fluticazonă 50 micrograme.Excipient cu efect cunoscut:o acţionare (doză de 0,14 g)
eliberează clorură de benzalconiu 0,014 mg. Forma farmaceutică: Spray nazal suspensie. Suspensie omogenă, albă. Indicaţii terapeutice: Ameliorarea simptomelor de rinită
alergică sezonieră şi perenă moderate până la severe dacă monoterapia cu antihistaminice intranazale sau glucocorticoizi nu este considerată suficientă. Doze şi mod de
administrare. Doze: Utilizarea regulată este esenţială pentru beneficiul terapeutic complet. Contactul cu ochii trebuie să fie evitat. Adulţi şi adolescenţi (în vârstă de 12 ani şi
peste această vârstă): O acţionare (doză) în fiecare fosă nazală de două ori pe zi (dimineaţa şi seara). Copii şi adolescenţi cu vârsta sub 12 ani: Dymista spray nazal nu este
recomandat pentru utilizare la copii cu vârsta sub 12 ani atâta timp cât siguranţa şi eficacitatea nu au fost stabilite la această grupă de vârstă. Vârstnici: Nu este necesară ajustarea
dozei la această categorie de populaţie.Insuficienţă renală şi hepatică: Nu există date privind experienţa clinică la pacienţii cu insuficienţă renală şi hepatică. Durata tratamentului:
Dymista spray nazal este adecvat pentru administrarea de lungă durată. Durata tratamentului trebuie să corespundă cu perioada de expunere alergenică. Mod de administrare:
Dymista Spray Nazal este destinat numai utilizării nazale. Instrucţiuni pentru utilizare: Pregătirea spray-ului; Flaconul trebuie agitat cu blândeţe cu aproximativ 5 secunde
înaintea administrării prin înclinarea acestuia în sus şi în jos, iar ulterior va fi înlăturat capacul protector. Înainte de prima utilizare a Dymista spray nazal, acesta trebuie amorsat
prin apăsare în jos, eliberând pompa, de 6 ori. Dacă Dymista spray nazal nu a fost utilizat timp de mai mult de 7 zile, acesta trebuie reamorsat o singură dată, prin apăsare în jos
eliberând pompa.Utilizarea spray-ului: Flaconul trebuie agitat cu blândeţe cu aproximativ 5 secunde înaintea administrării prin înclinarea acestuia în sus şi în jos, iar ulterior va fi
înlăturat capacul protector. După suflarea nasului suspensia va fi pulverizată o singură dată în fiecare nară ţinând capul înclinat în jos. După utilizarea spray-ului vârful flaconului
va fi şters, iar capacul protector va fi repus. Contraindicaţii: Hipersensibilitate la substanţele active sau la oricare din excipienţi. Atenţionări şi precauţii speciale pentru
utilizare: După punerea pe piaţă au existat raportări referitoare la interacţiuni medicamentoase semnificative din punct de vedere clinic la pacienţii trataţi cu propionat de
fluticazonă şi ritonavir care au determinat efecte corticosteroide sistemice inclusiv sindrom Cushing şi supresia corticosuprarenalei. De aceea, utilizarea concomitentă a propionatului
de fluticazonă şi ritonavir trebuie evitată, cu excepţia cazului în care beneficiul potenţial depăşeşte riscul reacţiilor adverse corticosteroide sistemice. Pot apărea reacţii adverse
sistemice după administrarea corticosteroizilor nazali, în special când aceştia sunt prescrişi în doze mari pentru perioade îndelungate, dar mult mai puţin probabil decât în cazul
administrării orale a corticosteroizilor şi pot varia de la pacient la pacient şi între diferite medicamente care conţin corticosteroizi. Potenţialele reacţii adverse sistemice pot include
sindromul Cushing, caracteristici cushingoide, supresia corticosuprarenalei, retard de creştere la copii şi adolescenţi, glaucom şi mult mai rar un spectru de reacţii psihologice sau
comportamentale incluzând hiperactivitate psihomotorie, tulburări de somn, anxietate, depresie sau agresiune (în special la copii şi adolescenţi). Dymista spray nazal este supus
unui proces metabolic de prim pasaj extensiv, de aceea este probabil ca expunerea sistemică să crească la pacienţii cu boală hepatică severă după administrarea intranazală a
propionatului de fluticazonă. Aceasta poate conduce la o frecvenţă mai mare a reacţiilor adverse sistemice. Se recomandă prudenţă în tratarea acestor pacienţi.Tratamentul cu
corticosteroizi administraţi nazal cu doze mai mari decât cele recomandate, poate conduce la o supresie semificativă clinic a corticosuprarenalei. Dacă există dovezi referitoare la
utilizarea de doze mai mari decât cele recomandate a fi utilizate, ulterior trebuie luată în considerare administrarea suplimentară de corticosteroizi sistemici în timpul perioadelor
de stres sau de intervenţii chirurgicale.În general doza de fluticazonă din formularea pentru administrare intranazală trebuie redusă la cea mai mică doză la care este menţinut un
control eficient al simptomelor de rinită. Retardul de creştere a fost raportat la copiii care au primit corticosteroizi administraţi nazal în doze aprobate. Retardul de creştere poate
fi de asemenea posibil şi la adolescenţi. Dacă creşterea este încetinită terapia trebuie revizuită cu scopul reducerii dozei de corticosteroid administrat nazal, dacă este posibil, la cea
mai mica doză la care este menţinut un control eficient al simptomelor. Tulburările de vedere pot apărea în cazul utilizării sistemice și topice de corticosteroizi. Dacă pacientul
prezintă simptome cum sunt vedere încețoșată sau alte tulburări de vedere, trebuie luată în considerare trimiterea sa la un oftalmolog pentru evaluarea cauzelor posibile care pot
include cataractă, glaucom sau boli rare, precum corioretinopatia centrală seroasă (CRSC), care au fost raportate după utilizarea sistemică și topică de corticosteroizi.Este necesară
o atentă monitorizare la pacienţii cu modificări de vedere sau la pacienţii cu antecedente de presiune intraoculară crescută, glaucom şi/ sau cataractă. Dacă există orice motiv să
credem că funcţia corticosuprarenalei este afectată, o atenţie deosebită trebuie avută în vedere atunci când se efectuează trecerea pacienţilor de pe tratamentul cu corticosteroizi
sistemici pe tratamentul cu Dymista spray nazal.La pacienţii care au tuberculoză, orice tip de infecţie netratată, sau care au suferit recent o intervenţie chirurgicală sau un
traumatism la nivelul nasului sau cavităţii bucale, beneficiul posibil al tratamentului cu Dymista spray nazal trebuie să depăşească riscurile posibile. Infecţiile căilor respiratorii
nazale trebuie tratate cu chimioterapice antibacteriene sau antimicotice, dar nu constituie o contraindicaţie specifică a tratamentului cu Dymista spray nazal.Dymista conţine
clorură de benzalconiu. Acesta poate produce iritaţii ale mucoasei nazale şi bronhospasm. Interacţiuni cu alte medicamente şi alte forme de interacţiune: Propionatul de
fluticazonă: Este de așteptat ca tratamentul concomitent cu inhibitori ai CYP3A, inclusiv cu medicamente care conțin cobicistat, să mărească riscul de reacţii adverse sistemice.
Administrarea concomitentă trebuie evitată, cu excepția cazurilor în care beneficiul obținut depășește riscul crescut de reacţii adverse sistemice induse de corticosteroizi, în acest
caz fiind obligatorie monitorizarea pacienților pentru depistarea reacţiilor adverse sistemice induse de corticosteroizi. Se recomandă o atenţie deosebită la coadministrarea unui
inhibitor potent al citocromului P450 3A4 (ex. ketoconazol), deoarece există un potenţial de expunere sistemică crescută la fluticazonă propionat. Clorhidrat de azelastină: Trebuie
acordată o atenţie deosebită atunci când se administrează clorhidrat de azelastină la pacienţii care primesc în acelaşi timp sedative sau alte medicamente cu acţiune la nivelul
sistemului nervos central, deoarece efectul sedativ poate fi amplificat. Alcoolul poate amplifica de asemenea acest efect. Fertilitatea, sarcina şi alăptarea: Fertilitatea. Sunt
disponibile doar date limitate referitoare la fertilitate. Sarcina. Dymista spray nazal trebuie utilizat în timpul sarcinii doar dacă beneficiile potenţiale justifică riscul potential asupra
fătului. Alăptarea. Dymista spray nazal poate fi utilizat în timpul alăptării, doar dacă beneficiile potențiale justifică riscul potenţial la nou născuţi/copii. Efecte asupra capacităţii
de a conduce vehicule şi de a folosi utillaje: Dymista spray nazal are o influenţă mică asupra capacităţii de a conduce vehicule sau de a folosi utilaje. În cazuri izolate atunci
când se administrează Dymista spray nazal pot apărea fatigabilitate, oboseală, epuizare, ameţeală sau slăbiciune, care pot fi de asemenea determinate de boala în sine. În aceste
cazuri poate fi afectată capacitatea de a conduce sau de a folosi utilaje. Alcoolul poate amplifica acest efect. Reacţii adverse: Foarte frecvente: epistaxis; Frecvente: cefalee,
disgeuzie (gust neplăcut), miros neplăcut; Mai puţin frecvente: discomfort nazal (incluzând iritaţie nazală, înţepături, măncărime), strănut, uscăciune nazală ,tuse, uscăciune în gât,
iritaţie la nivelul gâtului; Rare: uscăciunea gurii; Foarte rare: hipersensibilitate incluzând reacţii anafilactice, angioedem (edem la nivelul feţei sau limbii, eritem cutanat),
bronhospasm, ameţeală, somnolenţă, glaucom, presiune intraoculară crescută, cataractă, perforaţie de sept nazal, eroziuni ale mucoasei, greaţă, eritem cutanat, prurit, urticarie,
fatigabilitate (oboseală, epuizare), slăbiciune; Cu frecventa necunoscută: vedere încețoșată. ulcerații nazale. În cazuri rare a fost observată osteoporoza, dacă glucocorticoizii au fost
administraţi nazal pentru o perioadă de timp îndelungată. Supradozaj: Pentru calea de administrare nazală nu sunt anticipate reacţii de supradozaj. În caz de supradozaj după
ingestia orală accidentală, pe baza rezultatelor studiilor experimentale la animale, pot fi aşteptate tulburări la nivelul sistemului nervos central (incluzând somnolenţă, comă,
tahicardie şi hipotensiune arterială) produse de clorhidratul de azelastină. Tratamentul acestor tulburări trebuie să fie simptomatic. Se recomandă lavajul gastric în funcţie de
cantitatea înghiţită. Nu există un antidot cunoscut. Lista excipienţilor: edeteat disodic, glicerol, celuloză microcristalină, carmeloză sodică, polisorbat 80, clorură de benzalconiu,
alcool feniletilic, apă purificată. Perioada de valabilitate: Flacoane cu 23 g suspensie în flacoane de 25 ml: 2 ani. Perioada de valabilitate în timpul utilizării (după prima
utilizare): 6 luni. Precauţii speciale pentru păstrare: A nu se păstra la frigider sau congela. Natura şi conţinutul ambalajului: Flacon din sticlă brună tip I prevăzut cu pompă
de pulverizare, aplicator nazal din polipropilenă şi capac protector, care conţine 23 g (cel puţin 120 de acţionări). Mărimi de ambalaj:1 flacon cu 23 g suspensie în flacoane de 25
ml (cel puţin 120 de acţionări). Deţinătorul autorizaţiei de punere pe piaţă: MEDA Pharma GmbH & Co. KG, Benzstraße 1.D-61352 Bad Homburg, Germania. Numărul
autorizaţiei de punere pe piaţă:11003/2018/01-04. Data primei autorizări sau a reînnoirii autorizaţiei: Autorizare – Aprilie 2013. Data ultimei reînnoiri a autorizaţiei:
Septembrie 2018. Data revizuirii textului: Ianuarie 2019. Acest medicament se eliberează pe bază de prescripție mediacală PRF. Pentru raportarea evenimentelor adverse vă
rugăm să utilizaţi următoarele date de contact: Tel.: 0372.579.004 Fax: 0371.600.328; Email: pv.romania@mylan.com.
 Tratament de primă alegere
în rinita alergică*,1,2

l Ameliorează semnificativ simptomele rinitei alergice,

începând de la 5 minute după administrare§,3
l De 2 ori mai eficace decât actualele terapii de primă linie4
l Conține două substanțe active, din clase terapeutice diferite și complementare:
fluticazonă propionat – CSIN și azelastină – AHIN5
l Recomandat de Ghidul ARIA 20166

* Rinita alergică sezonieră și perenă, moderată până la severă. CSIN: corticosteroid intranazal
§ Vs. placebo; studiu de expunere controlată la alergeni. AHIN: antihistaminic intranazal
1. Carr W et al. J Allergy clin immunol 2012;129(5):1282-89.
016_09_09-19_LB-Dymi-RO

2. Leung DYM et al. the Editors’ choice – MP29-02: a major advancement in the treatment of allergic rhinitis. J Allergy clin immunol 2012;129(5):1216.
3. Bousquet J et al. The Journal of Allergy and Clinical Immunology: In Practice (2018), doi: 10.1016/j.jaip.2018.01.031.
4. Meltzer E et al. Int Arch Allergy immunol 2013;161(4):369-77.
5. Dymista – Rezumatul Caracteristicilor Produsului
6. Brozek J et al. Allergic Rhinitis and its Impact on Asthma (ARIA) Guidelines – 2016 Revision. JACI 2017; DOI:10.1016/j.jaci.2017.03.050. JACI 2017
Floreasca Business Park, Calea Floreasca 169A, Acest material promoţional este destinat exclusiv profesioniștilor din domeniul sănătăţii.
Corp B, Parter, cod poștal 014459, sector 1, Informaţiile de prescriere a medicamentului sunt atașate în interiorul acestui material.
București; Telefon: 0372 579 000; Fax: 0371 600 326. Pentru informaţii detaliate consultaţi Rezumatul Caracteristicilor Produsului.
 interdisciplinary

Sorin
Ibric-Cioranu,
Vlad Petrescu-
Seceleanu
ENT Section, Department
of Oro-Maxilo-Facial Surgery,
“Elias” University Emergency
Hospital, Bucharest
Follow-up in advanced
basal-cell carcinoma
Abstract
Skin malignancies usually take the form of basal cell
car­ci­no­ma, squamous cell carcinoma and malignant
me­la­no­ma. The head and neck malignant tumor pa­tho­
logy can be addressed by multiple medical specialists:
maxil­lo­fa­cial surgeons, dermatologists and plastic
sur­geons. Although considered a less aggressive type
of malignancy, the basal-cell carcinoma can extend to
pro­found regions and require extensive surgery and im­
mediate reconstructions of the defect area with regional
or distant flaps. The treatment does not end with the
sur­gi­cal phase, the follow-up being as equally important,
as there is a 50% higher risk for developing a second skin
malig­nan­cy in the next 5-10 years postoperatively.
Keywords: basal-cell carcinoma, surgical extirpation,
relapse, local flap
Rezumat
Tegumentul poate fi afectat de tumori maligne, cu pre­pon­
de­rență carcinomul bazocelular, urmat de cel spi­no­ce­lu­lar
și melanomul malign. Patologia tumorală malig­nă din
zona capului și a gâtului se află la granița din­tre multiple
specialități: chirurgie maxilo-facială, der­ma­to­lo­gie, chirurgie
plastică. Deși considerat o formă mai pu­țin agresivă local,
carcinomul bazocelular poate avea o evoluție locoregională
infiltrativă în părțile profunde, im­pli­când rezecții largi și
reconstrucție imediată cu lam­bouri locoregionale sau de la
distanță. De asemenea, diag­nos­ti­ca­rea cu o formă de neoplazie
tegumentară crește riscul de apa­ri­ție a unei noi neoplazii în
următorii 5-10 ani cu peste 50%, astfel încât tratamentul nu
este considerat încheiat oda­tă cu etapa rezectivă chirurgicală.
Cuvinte-cheie: carcinom bazocelular, extirpare extinsă,
recidivă, lambou local

Submission date:
2.05.2019 Urmărirea pacienţilor cu carcinom bazocelular
Acceptance date: Suggested citation for this article: Ibric-Cioranu S, Petrescu-Seceleanu V. Follow-up in advanced basal-cell carcinoma. ORL.ro. 2019;44(3):24-27.
10.05.2019

Introduction The relapse or lymph metastasis risk is associated

Skin cancer is the most frequent malignancy world-
wide. The most encountered histological subtypes are
basal-cell carcinoma and squamous cell carcinoma.
Only in 2012, in USA, up to 5 million patients received
treatment for these two types of cancer(1). Australia
has the highest number of new cases of skin cancer in
the world(2), due to climate (extensive sun exposure);
the vast majority of skin malignant tumours are UV
radiation dependent.
In the European Union, there is a 2-3% increase
in new cases, according to a 10-year retrospective
study (3).
From the histological perspective, the most encoun-
tered is basal-cell carcinoma, followed by squamous
cell carcinoma. Most of the basal-cell carcinomas are
found in the head and neck region (over 80%).
The management of skin malignancies is divided
into two major branches: surgery (radical tumor resec-
tion, Mohs surgery, electrodessication), and conserva-
tive treatment (photodynamic therapy, radiotherapy,
cryotherapy and topical agents).
Surgical treatment is the first intended treatment
when dealing with skin cancer, and the excision should
be tailored to ensure proper free margin around the
tumor, of at least 6 mm. If the lesion is found to be
generated from the squamous layer, the lymph nodes
should also be investigated.
with the characteristics of the tumour: histological
subtype, size, profound invasion, localization, and
also the general condition of the patients (immuno-
suppression, severe associated diseases). The tumors
associated with a high risk of relapse or metastases
have poor differentiated morphology, have more than
2 cm in size, and are situated in the eye or in perioral
region(4).
The follow-up for these patients should be on an
annual base; over 90% of relapses occur in the first
five years postoperatively (5). Usually, when dealing
with skin cancer, the prognosis is good, except when
there is lymph node involvement or distant metasta-
sis; then the survival rate drops by 50% for women
and by 30% for men(6).
Case presentations
Case I
An 82-year-old male patient was admitted to our
department for a frontal region tumor developed ap-
proximately six months ago (Figure 1.1). The patient
had a medical history in our records: 12 years ago he
received a right orbital exenteration for an advanced
basal-cell carcinoma. The clinical examination revealed
an ulcerated endophytic tumor in the right paramedian
frontal region, of irregular shape, 3/2 cm in diameter,
with ill-differentiated, firm borders and the bottom of

24 Year XII • No. 44 (3/2019)

 Figure 1.1. Frontal basal-cell carcinoma 12 years after
exenteration
the ulceration covered with crusts; the tumor was not
fixed to the underlying bony bed. The biopsy confirmed
a secondary basal-cell carcinoma. A surgical plan was
established: wide surgical excision and immediate re-
construction of the defect with advanced horizontal
frontal flap (Figure 1.2). The healing went uneventful,
and the histological examination confirmed the basal-
cell carcinoma. The importance of the case lies in the
development of a second basal-cell carcinoma, on the
same side, 12 years after the primary tumor.
Case II
An 81-year-old female patient was sent to our de-
partment by her general practitioner for an ulcerated
left cheek tumor, with a five-year onset (Figure 2.1).
After the clinical and computed tomography exami-
nations (Figure 2.2), the preliminary diagnosis was
basal-cell carcinoma of the left cheek region extend-
ing in the orbital and nasal region. The tumor was
ulcerated, exophytic, covered by crusts, with irreg-
ular borders and fixed to the underlying maxillary
wall, 35/30 mm in size, with multiple blood vessels
on the tumor’s surface. The ophthalmic examination
revealed important eyesight impairment. The patient
did not have other illnesses.
The biopsy confirmed the clinical diagnosis: ba-
sal-cell carcinoma. A surgical procedure was planned:
wide surgical excision en bloc with left exenteration
and anterior maxillary wall resection, and immediate
reconstruction of the soft tissue defect with fron-
tal and advanced cheek flap (Figure 2.3). A second-
stage procedure will be carried on after three weeks
for adjusting the frontal flap pedicle. Healing went
uneventful (Figure 2.4). The patient refused other
surgical procedures.
Year XII • No. 44 (3/2019)
Figure 1.2. Upper left: the flap design for recons­truc­
tion; lower left: flap in place; right: follow-up at 6 months
Discussion
There are numerous reports in literature that show
an increase in skin cancer incidence, but an exact
number cannot be determined because of a variety
of factors: not all excised specimens are sent for histo-
logical examination, many patients are treated in one-
day surgery procedures in private centres that do not
usually report all their malignant cases and, last but
not least, because skin malignancies are often seen
in elderly patients which may not receive adequate
treatment due to their health condition.
Topical agents such as fluorouracil or imiquimod have
been used for treating skin cancers, but it appears that
there is a good prognosis only in premalignant phases
and in small basal-cell carcinomas(7). Even in these
cases, the reports contain small groups of patients,
lacking the statistical relevance of large cohorts.
Cryotherapy has a high relapse rate – over 40%(8) –
because the clinician cannot ensure rigorous safety
margins.
It is best suited for a palliative method of treatment
in patients who are not good candidates for surgical
treatment.
Radiotherapy can enhance the prognosis when
dealing with relapse or node involvement, when it is
used after the surgical treatment in the multimodal
treatment of skin cancers.
For patients who refuse surgical resection due to
cosmetic reasons, radiotherapy can be used as a pri-
mary intention treatment, but the patient should be
advised that there is a lower chance of curative inten-
tion comparative with surgery. When used alone, in
advanced stages,­there is a recurrence rate of up to
50% during the first five years post-treatment(9).
25
interdisciplinary
Figure 2.1. Basal-cell carcinoma of the cheek area
involving the orbit and the nose regions
Figure 2.3. Surgical specimen, the defect, and the flap
design
For late stages of squamous cell carcinomas with
lymph node involvement, the most efficient therapy
is the surgical treatment (resection and neck dissec-
tion) followed by radiotherapy.
When dealing with N0 stages, neck management
must be carefully planned and the cervical nodes
should be addressed when there is perineural or
perivascular infiltration, poorly differentiated his-
tological types, immunosuppression, more than 2
26
Figure 2.2. CT scan showing bony and orbit extension
of the tumor
Figure 2.4. Immediate postoperative image and after
suture removal
cm in size or 8 mm depth of the primary tumor (10).
Patients who have developed a skin malignancy pose
a greater risk of acquiring a second tumor in time
and they are three times more likely to develop a
malignant melanoma(11).
Specialists recommend to have check-ups twice a
year and protection against UV.
The various drug therapies have not yet been proved
to play a major role in fighting relapse or metastasis.
Year XII • No. 44 (3/2019)
Conclusions
The European population tends to get older and
as skin cancers are age-dependent, the clinicians will
have to deal in the future with an increasing number
of patients. The vast majority of skin malignancies are
found in the head and neck regions, where multiple
1. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM, Incidence Estimate of Non-
References
melanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012.
JAMA Dermatol. 2015 Oct; 151(10):1081-6. doi: 10.1001/jamadermatol.2015.1187
2. Australian Insistute of Health and Welfare.Health System Expenditures on Cancer
and Other Neoplasms in Australia, 2000-2001. Canberra: AIHW, 2005; (Cat. no. HWE
29.) Available at: http://www.aihw.gov.au/publication-detail/?id=6442467719
3. Rudolph C, Schnoor M, Eisemann N, Katalinic A. Incidence trends of non-
melanoma skin cancer in Germany from 1998 to 2010. J Dtsch Dermatol Ges. 2015;
13:788e97.
4. Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous
squamous cell carcinoma. J Am Acad Dermatol. 1992; 27(2 Pt 1):241-248.
5. Glogau R. The risk of progression to invasive disease. J Am Acad Dermatol. 2000;
42:23-4.
6. Steding-Jessen M, Birch-Johansen F, Jensen A, et al. Socioeconomic status and
non-melanoma skin cancer: a nationwide cohort study of incidence and survival
Year XII • No. 44 (3/2019)
medical specialists exert their profession, but a better
collaboration between professions will ensure a better
prognosis for these patients. n
Conflict of interests: The authors declare no con-
flict of interests.
in Denmark. Cancer Epidemiol. 2010; 34(6):689–95.
7. Gross K, Kircik L, Kricorian G. 5% 5-Fluorouracil cream for the treatment of small
superficial basal cell carcinoma: efficacy, tolerability, cosmetic outcome, and
patient satisfaction. Dermatol Surg. 2007; 33:433-9; discussion 440.
8. Hall VL, et al. Treatment of basal-cell carcinoma: comparison of radiotherapy and
cryotherapy. Clin Radiol. 1986 Jan; 37(1):33-4.
9. Lee WR, Mendenhall WM, Parsons JT, Million RR. Radical radiotherapy for T4
carcinoma of the skin of the head and neck: a multivariate analysis. Head Neck.
Jul-Aug 1993; 15(4):320-324.
10. Palyca P, Koshenkov VP, Mehnert JM. Developments in the treatment of locally
advanced and metastatic squamous cell carcinoma of the skin: a rising unmet
need. Am Soc Clin Oncol Educ Book. 2014; e397–e404. doi:10.14694/EdBook_
AM.2014.34.e397
11. Rees JR, Zens MS, Gui J, Celaya MO, Riddle BL, Karagas MR. Non-melanoma skin
cancer and subsequent cancer risk. PLoSOne. 2014; 9(6):e99674.
27
 interdisciplinary
Andreea Dona
Iordan-Dumitru1,
Agnes Katherine
Lackner2,
Andrei Kozma3,
Horia Lăzărescu4,
Doriana Agop
Forna5,
Vasilica Toma6
1. MD, PhD, Assist. professor,
Faculty of Dental Medicine,
“Titu Maiorescu” University,
Bucharest, Romania
2. MD, Department
of Pediatric Dentistry,
University Dental Clinic,
Medical University of Vienna,
Austria
3. Sen. res. II, PhD, MMD,
MDH, Research Department,
“Alessandrescu-Rusescu”
National Institute for Mother
and Child Health,
Bucharest, Romania
4. PhD, MD, CS II,
National Institute
for Recovery,
Physical Medicine
and Balneoclimathology,
Bucharest, Romania
5. MD, PhD, Lecturer,
Faculty of Dental Medicine,
“Grigore T. Popa” University
of Medicine and Pharmacy,
Iaşi, Romania
6. MD, conf. univ. dr.,
Department of Surgery,
Pedodontics Discipline,
Faculty of Dental Medicine,
“Grigore T. Popa” University
of Medicine and Pharmacy,
Iaşi, Romania
Corresponding author:
Andrei Kozma
E-mail: dr.ka.mailbox@gmail.com
Horia Lăzărescu
E-mail: horialazarescu@
yahoo.com
Acknowledgement:
All authors contributed
equally to the study.
No funding for this study.
28
Study on the prevalence,
diagnosis, therapeutic
management and complications
of supernumerary teeth
Abstract
Aim. This descriptive study reveals clinical and paraclinical
aspects related to the presence of supernumerary teeth
in children with severe general disorders. Materials and
method. The study based on clinical, epidemiological
and radiological assessment was performed on a batch of
1651 urban patients from whom a batch of 7 patients with
familial and complex history and supernumerary teeth was
chosen. Results and discussion. In the study group, the
most common morphological form of supernumerary tooth
encountered was the mesiodens with nano crown, in the
form of a stake present in four of the seven cases clinically
and radiologically supervised, and the predilection was the
upper jaw. The results are in line with those in the specialized
literature. Conclusions. Early treatment can solve the
shortcomings caused by the presence of supernumerary
teeth, if the anomaly is diagnosed early. Any sign of late
eruption longer than 8 months compared to the eruption
of the counterpart should be investigated radiologically.
Keywords: supernumerary, mesiodens, clinical aspect,
radiological aspect, treatment
Submission date:
20.06.2019 Studiu asupra prevalenţei, diagnosticului, managementului terapeutic
Acceptance date:
5.08.2019 şi a complicaţiilor dinţilor supranumerari
Suggested citation for this article: Iordan-Dumitru AD, Lackner AK, Kozma A, Lăzărescu H, Agop Forna D, Toma V. Study on the prevalence, diagnosis, therapeutic
management and complications of supernumerary teeth. ORL.ro. 2019;44(3):28-34.
Introduction
Supernumerary teeth are dental units that numeri-
cally exceed the normal dental formula, a phenomenon
also known as hyperdontosis (extra teeth, duplicates,
cones or aberrant teeth), which occurs in solitary or mul-
tiple forms, uniquely or bilaterally affecting both jaws.
The prevalence of supernumerary teeth ranges be-
tween 0.1% and 0.8% in temporary dentition and be-
tween 0.1% and 3.8% in permanent teeth(1-4). Boys are
two times more affected than girls, and the jaw is 8.2-10
times more affected than the mandible(1-4). There is a
significant association between supernumerary teeth
and invaginated teeth explained by the different em-
bryological development of the premaxillary(2).
Rezumat
Scop. Acest studiu descriptiv relevă aspecte clinice şi paraclinice
legate de prezenţa dinţilor supranumerari la copii cu afecţiuni
generale grave. Materiale și metodă. Studiul, bazat pe
analiza clinică, epidemiologică şi pe evaluare radiologică, a
fost efectuat într-un cabinet cu practică privată din București,
pe un lot de şapte pacienţi cu istoric familial şi general
complex şi cu dinţi supranumerari. Rezultate și discuții.
S-a constatat că meziodensul se regăsește la ambele sexe în
mod relativ egal, neexistând diferențe majore între femei şi
bărbaţi. În lotul nostru de studiu, cea mai frecventă formă
morfologică de dinte supranumerar întâlnită este meziodensul
cu coroană nanică, în formă de țăruș, prezent în patru din cele
şapte cazuri supravegheate clinic şi radiologic, iar localizarea
predilectă este premaxilarul. Rezultatele sunt în concordanță
cu cele din literatura de specialitate. Concluzii. Tratamentul
timpuriu poate rezolva neajunsurile produse de prezența
dinților supranumerari, în condiţiile în care anomalia este
diagnosticată devreme. Orice semn de erupție întârziată mai
mare de opt luni față de erupția omologului trebuie investigat
radiologic.
Cuvinte-cheie: supranumerar, meziodens, aspect clinic,
aspect radiologic, tratament
Etiology
P.V. Rao(1) considers that the etiology of supernumer-
aries is multifactorial, involving genetic factors and envi-
ronmental factors, based on theories that try to explain
their occurrence (Table 1).
A number of genetic syndromes are associated with
the presence of supernumerary teeth and the gene lo-
calization is already known(6,14) (Table 2).
Clinical and paraclinical aspects
The unilateral persistence of a temporary tooth in
the premaxillary area, the eruption delay, the impac-
tion or the ectopic eruption of a permanent incisor, the
severe inter-incisive diastema or the rotation of perma-
nent incisors or dento-alveolar disharmony with frontal
Year XII • No. 44 (3/2019)
Table 1 Etiopathogenic theories
Genetic disorder Etiopathogenic theories
Atavism The result of phylogenetic reversal in extinct primates with three pairs of incisors
It considers that the dental bud is divided into two parts of equal or different dimensions that
The theory of dichotomy
evolve independently
It takes into consideration the independent, conditioned hyperactivity of the dental blade with
The theory of dental blade hyperactivity the supplementation of the lingual extension of an accessory bud or the proliferation of dental
blade epithelial remains strongly supported by specialized literature
Family gender linked heredity

Table 2 Genetic syndromes associated with supernumerary teeth

Syndrome Gene
LMP cleft
Gardner’s syndrome APC (611731)
Cledo-cranial dysplasia RUN X2 (600211)
Ehlers-Danlos syndrome PLOD (1534554)
Incontinentia pigmenti NEMO (301249)
Fabry syndrome GLA (300644)
Ellis van Creveld syndrome EVC (604831)
Noonan syndrome
Trico-rhino-phalangian syndrome
Zimmerman-Laby syndrome

Table 3 Classification of supernumerary teeth

Prevalence Localization Clinical aspect Radiological aspect
Located Conoid structures with reduced volume, with
Conic Conical or triangular crowns,
75% on the upper jaw conical or triangular crowns, fully formed roots,
supernumeraries fully formed roots
inter-incisor isolated (mesiodens) or bilateral (mesiodentes)
Crowns in the form of a screwdriver and additional
Located Radiological appearance
Tuberculed cusps, absent or incomplete roots, palatal
12% on the upper jaw with absent or incompletely
supernumeraries localized, behind the maxillary centrals, often
inter-incisor formed root
in pair, representing the third dentition
Radiological aspect with
Located anterior They are benign hemartomas that contain all well-defined radiopaque
on the maxillary dental tissues with small teeth in volume lesions, surrounded by
Odontomum -6%
and posterior as a single structure or non-irregular body in two a radio-transparent band
on the mandible clinical forms: compound and complex and containing radio opacity
with an aspect of nanic tooth

Year XII • No. 44 (3/2019)

29
interdisciplinary

crowding alert the clinician to the possible presence of
supernumerary teeth and require a radiological investi-
gation to confirm the diagnosis. Their classification may
be done morphologically and according to localization
(Table 3)(2,3,11,8).
The most useful radiographic investigation is ortho-
pantomography with additional images on periapical
and occlusal radiographs. For the localization of a non-
erupted supernumerary, parallax method is recommen­
ded with two separate X-rays from different angles for
the same region or cone beam CT that provides detailed
3D imaging of the zonal structures(2,3).
Accidentally discovered in the radiological examina-
tion, the supernumerary tooth may associate complica-
tions including delayed eruption of permanent teeth
in the area of interest, impaction or ectopic eruptions,
severe rotations of adjacent teeth, dento-alveolar crowd-
ing or diastema which cannot be closed orthodontically,
root resorption or development of follicular cysts.
Materials and method
Clinical analysis – two assessors examined the super-
nn
numerary teeth morphology through visual inspection.
Visual examination of orthopantomographies – two
nn
evaluators examined retro-dento-alveolar radiographs
and orthopantomographies in the study group, with
a 96.7% concordance between examiners.
Statistical analysis used the T student test and freque­
nn
ncy analysis, which were done using SPSS 13.00
software.
The study group
The study was performed on a group of 1651 pa-
tients, 52% boys and 48% girls, aged between 6 and 15
years old, over a one-year period (2017-2018). For the
epidemiological study, the number, shape and volume
of supernumerary teeth were taken into account: gen-
der, age and ethnicity, dental history and radiological
balance.
From the study group, seven cases presented mesi-
odens, indicating a prevalence of 0.42%. Gender dis-
tribution reveals a modest percentage in favor of male
gender, but the reduced size of the affected group does
not allow valid conclusions about the relatively equal
affection of the two sexes.
The environment of origin is dominated by the urban
area with higher addressability and in the absence of
dental practices in villages.
The distribution of the study group by age group is
heterogeneous: the age of 9 is predominant.

Figure 1. Distribution by gender: 52% boys and 48% girls Figure 2. Distribution of the study group by place of origin

Table 4 Distribution of the study group by age

Frequency Percentage Valid percentage Cumulative percentage
6 1 14.3 14.3 14.3
7 1 14.3 14.3 14.3
9 2 28.6 28.6 28.6
11 1 14.3 14.3 14.3
12 1 14.3 14.3 14.3
15 1 14.3 14.3 14.3
Total 7 100

30 Year XII • No. 44 (3/2019)

Results and discussion
Although age is an important factor in assessing
the prevalence of dental abnormalities for the study of
supernumerary teeth, this parameter is considered to
be inaccurate because there is no specific age at which
supernumerary teeth begin to develop; they may occur
in temporary, mixed or permanent dentition in the pre-
maxillary region or in any region of the dental arcade.
Even the absence of supernumerary teeth at a certain age
does not imply, with certainty, that the patient will not
present supernumeraries later; it only indicates that, at
the time of the examination, there are no supernume­
rary dental buds(2,3).
Family history and dental history are critical factors
that influence the prevalence values of supernumeraries
in our study group(7,11,12,13).

Case 1
The first patient was an 11-year-old boy diagnosed
with Trico-oculo-dental syndrome, the first newborn
of a 38-year-old pregnant mother with type 1 diabe-
tes mellitus developed with delayed dis-pregnancy, the
birth being at term, with dystocia, by caesarean section,
the newborn weighing 4100 g, with normal postnatal
development.
General clinical examination reveals moderately pale
skin, excessive adipose tissue on the chest and limbs,
dismorphic facies, hypertelorism, epicanthus, thick eye-
brows, flattened nose root, bilateral congenital cataract
confirmed by olological examination, and mental retar-
dation with QI 41 (Figure 3).
At the facial level, there is a small mouth with the
corners facing downwards, a retrognathic profile. The
functional examination revealed functional disorders of
mastication, phonation and physiognomy.
The endobucal examination (Figure 4) in mixed den-
tition shows, on the upper jaw median line, behind the
upper central incisors, a supernumerary tooth (mesio­
dentes) in the form of a screwdriver, intervestibular
rotations of the central incisors, a 3-mm inter-incisive
diastema with divergent dental axes.
The radiological examination reveals mixed denti-
tion, a supernumerary tooth located intraosseous, at the
Figure 3. Patient case 1. Male, 11 years old. Extraoral
clinical appearance
apex of 21, with an abnormal position, almost parallel
to the occlusal plane, with the tip pointing to the crown
of the dental bud of 23 (Figure 5).
Case 2
Another patient was a female aged 15 years old, the
first newborn of a 35-year-old primiparous mother with
a pigmented nevus in the left deltoid region, coming
from an unmonitored pregnancy, the child being born
on term, with a weight of 2700 g, with a good postnatal
evolution. She was hospitalized in the territorial hospi-
tal at the age of 8 years old for a respiratory infectious
episode. She presents skin hypopigmentation spots,
concentration deficiency and psychomotor deficiency,
29 kg weight hypotrophy, papular rash in the face and
upper limbs with hypochromic areas disposed along the
Blaschko lines.
The dermatological examination of the skin le-
sions associated with the presence of neuropsychiatric

a b c
Figure 4. Patient case 1. Male, 11 years of age. Intraoral clinical appearance: a) frontal; b) maxilary oclusal view; c)
mandibular oclusal view

Year XII • No. 44 (3/2019)

31
interdisciplinary
Figure 5. Patient case 1. Male, 11 years of age.
Radiological appearance
disorders and corroborated with the genetic exami-
nation lead to the diagnosis of Ito hypomelanosis.
Microcrania, mild facial asymmetry, and skin allergy
areas are highlighted. The patient has definitive denti-
tion, poor hygiene and a supernumerary, nanic tooth,
with ectopic eruption, inter-incisive at the jaw level
(Figure 6).
The patient was advised to have a radiological check-
up to see exactly the shape and size of the root, as well
as its position in relation to the surrounding tissues, and
she was recommended, as treatment, the extraction of
the mesiodens.
Some cases of supernumerary teeth are asymptoma­
tic and accidentally detected at the radiological exam.
Dental buds with late onset of mineralization can give
a false positive diagnosis of supernumerary tooth on
radiographs(7,9,11).
Case 3
This is also the case of a 9.4-year-old male patient
with marked weight hypotrophy and moderate hepato-
splenomegaly, facial dismorphism, larger ears, lowered
oral commissures, who was diagnosed with mucopoly-
saccharidosis confirmed by alpha-l iduronidase dosing
Figure 6. Patient case 2. Female, 15 years of age.
Intraoral appearance
32
in fibroblasts and leukocytes. The radiological exam
revealed a supernumerary tooth included (Figure 7).
Case 4
In the case of a 7-year-old male patient diagnosed
with palatal cleft operated about 6 years ago and pater-
nal heredity of congenital malformation, the orthopan-
tomograph reveals the mesiodens located between 51
and 61, as well as the presence of a supernumerary tooth
in quadrant 2. Since both 62 and the supernumerary
tooth are located very close to the palatoplasty line, it
was decided to send the patient to a buccal-maxillofacial
surgery service (Figure 8).
The treatment of supernumerary teeth depends on
the type of morphology, position, associated complica-
tions, patient’s age and dental cooperation, the radiologi-
cally appreciated radial length and the program of root-
formation of the adjacent teeth, and it consists in the
surgical extraction of the supernumerary tooth or, more
rarely, the repositioning in the dentoalveolar arch(3,9,10).
Case 5
In a female patient, aged 12 years old, it was decided
to extract the mesiodens using local anesthesia. She is
the first newborn of a 30-year-old primiparous mother
with minor thalassemia from a monitored pregnancy
with late dis-pregnancy, the child being born on term,
with a birth weight of 2400 g, with good postnatal pro-
gression. At the age of 1 year and a half, she was admitted
to a pediatric hospital in Bucharest for an intercurrent
superior respiratory infection; pale skin and mucosa,
and splenomegaly were highlighted.
The haemogram showed hypochromic anemia, and
the smear revealed an increased number of reticulocytes
and cells in the form of target shooting, suggestive of
thalassemia. Pathological hemoglobin electrophoresis
was performed, showing a high percentage of fetal hemo-
globin and A2 hemoglobin. At the age of one years old,
the child returns to the pediatric-hematology depart-
ment for isogroup/isoRh blood substitution-transfusion
Figure 7. Patient case 3. Male, 9 years of age.
Radiological aspect
Year XII • No. 44 (3/2019)
treatment. At the intraoral examination, a supernumer-
ary tooth with a conical and sharpened appearance (Fig-
ure 9a) was observed. The patient was advised to have
a radiological examination in order to assess the shape
and size of the root and its position in relation to sur-
rounding tissues (Figure 9b).
Treated through the surgical extraction of the super-
numerary tooth, partially palatally erupted, with incom-
pletely formed root, the patient was carefully monitored
intrasurgically and taken care of until healing. The place
of extraction was healed in about 15 days and the patient
was able to resume her masticatory function without
pain or discomfort (Figure 10).
In our study group, the most common morphologi- Figure 8. Pacient case 4. Male, 7 years of age.
cal form of supernumerary tooth is the mesiodens with Radiological aspect
nanic crown, in the form of a stake, present in four of
the seven cases clinically and radiologically monitored, The reported prevalence of 0.42% and the equal gen-
as in the studies by Fadi Ata-Al and Daijit S. Gill(2,3). The der distribution should be considered with caution due
number of supernumerary teeth diagnosed in two cases to the relatively small number of patients in the study
is double and the other cases in the study group present group, as in the study by Anthonappa(7,11,13).
a single supernumerary tooth located in the jaw, as in the The late eruption of the maxillary incisors is associ-
studies by Fadi Ata-Al and Daijit S. Gill(2,3,4,6). The pre- ated with Caucasians, in the proportion of 20-60%,
dilect localization of supernumerary teeth in the batch and with the presence of supernumerary teeth(2,3)
is the maxillary inter-incisive area, as in the study by especially from the tuberculed morphological type.
Fadi Ata-Al(2,3,6,8). Three of the seven cases in our study group had de-
The family history and the complex, debilitating and layed eruptions of the adjacent upper fronts. Any sign
hereditary inherited general disorders are essential vari- of eruption that is more than eight months late in
ables to be reported in supernumerary teeth studies(2,3,10). relation to the eruption of the counterpart should be

a b
Figure 9. Patient case 5. Female – intraoral (a) and radiological (b) aspect

a b c
Figure 10. Patient G.D., female. Treatment by surgical extraction; the aspect of the extracted mesiodens and the aspect of
the post-extractional wound

Year XII • No. 44 (3/2019)

33
interdisciplinary
investigated radiologically. Patients with a history
of conical or tuberculed supernumeraries at younger
ages have 24% chances(3) to develop unique or mul-
tiple supernumerary premolars, and this is why it is
necessary to have periodic radiological monitoring
in mixed teeth.
Conclusions
1. The reported prevalence of 0.42% and the equal
gender distribution should be considered with caution
due to the relatively small number of patients in the
study group. In our study group, the most common mor-
phological form of supernumerary tooth is the mesi-
odens with nanic crown, in the form of a stake.
2. The predilect localization of supernumerary teeth
in the batch is the maxillary inter-incisive area.
3. Supernumerary teeth have erupted ectopically by
producing dental congestion or preventing the erup-
tion of neighbouring teeth in three of the seven cases
included in the batch.
4. Supernumerary teeth produce functional disor-
ders especially in the physiological sphere and phonation
disorders.
5. Clinical and radiological examinations are essential
in the diagnosis of supernumerary teeth.
6. The radiological examination identifies the pres-
ence, the coronary and root shape of the supernumerary
1. Rao PV. Supernumerary molar teeth: observations in the skulls. Cent Afr J Med.
References
1999; 45: 324–327.
2. Ata-Ali F, Ata-Ali J, Peñarrocha-Oltra D, Peñarrocha-Diago M. Prevalence,
etiology, diagnosis, treatment and complications of supernumerary teeth. J Clin
Exp Dent. 2014; 6(4):e414-8.
3. Shah A, Gill DS, Tredwin C, Naini FB. Diagnosis and Management of
Supernumerary Teeth. Dent Update. 2008; 35: 510-520.
4. Gabris K, Fabian G, Kaan M, Rozsa N, Tarjan I. Prevalence of hypodontia and
hyperdontia in paedodontic and orthodontic patients in Budapest. Community
Dent Health. 2006; 23: 80−82.
5. Guttal KS, Naikmasur VG, Bhargava P, Bathi RJ. Frequency of developmental
dental anomalies in the Indian population. Eur J Dent. 2010; 4: 263–269.
6. Brook AH, Elcock C, al-Sharood MH, McKeown HF, Khalaf K, Smith RN. Further
studies of a model for the etiology of anomalies of tooth number and size in
humans. Connect Tissue Res. 2002; 43(2-3): 289−295.
7. Anthonappa RP, King NM, Rabie ABM. Diagnostic tools used to predict the
prevalence of supernumerary teeth: a meta-analysis. Dentomaxillofacial
Radiology. 2012; 41, 444–449.
8. Khalaf K, Robinson DL, Elcock C, Smith RN, Brook AH. Toothsize in patients with
34
tooth, the proximity to the permanent teeth and their
stage of root formation, it allows the positive diagnosis,
it orients the treatment, and it monitors the occurrence
of new single or multiple supernumeraries.
7. Early diagnosis and appropriate management
can minimize complications caused by supernumer-
ary teeth.
8. The treatment indicated in patients examined is ex-
traction and it depends on the age of the patient, dental
cooperation, locally induced complications, and the root
formation program of the adjacent permanent teeth.
9. Interdisciplinary management for cases in the
study group is the solution for a correct diagnosis and
for well-guided and periodic treatment.
10. General dentists should be informed about clinical
signs and therapeutic options in the cases of supernu-
merary teeth. n
Compliance with ethics requirements: The authors
declare that all the procedures and experiments of this study
respect the ethical standards of the Helsinki Declaration from
1975, as revised in 2008, as well as the national law. The
informed consent was obtained from the patients included
in the study.
Conflict of interests: The authors declare no con-
flict of interests.
supernumerary teeth and a control group measured by image analysis system.
Arch Oral Biol. 2005; 50: 243−248.
9. Tyrologou S, Koch G, Kurol J. Location, complications and treatment of
mesiodentes − a retrospective study in children. Swed Dent J. 2005; 29: 1−9.
10. Kramer PF, Feldens CA, Ferreira SH, Spiguel MH, Feldens EG. Dental anomalies
and associated factors in 2- to 5-year-old Brazilian children. Int J Paediatr Dent.
2008; 18: 434–440.
11. Anthonappa RP, Omer RS, King NM. Characteristics of 283 supernumerary teeth
in southern Chinese children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2008; 105: e48–e54.
12. Backman B, Wahlin YB. Variations in number and morphology of permanent
teeth in 7-year-old Swedish children. Int J Paediatr Dent. 2001; 11: 11–17.
13. Varela M, Arrieta P, Ventureira C. Non-syndromic concomitant hypodontia
and supernumerary teeth in an orthodontic population. European Journal of
Orthodontics. 2009; 31, 632–637.
14. Fleming PS, Xavier GM, DiBiase AT, Cobourne MT. Revisiting the supernumerary:
the epidemiological and molecular basis of extra teeth. British Dental Journal.
2010 Jan 9; 208(1):25-3.
Reclamă ORL 44(3)0106
Year XII • No. 44 (3/2019)
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References
1. Cochlear Limited. D1593476. Cochlear Nucleus Reliability Report, Volume 17 December 2018. 2019, Mar.
2. Hearing Implant Reliability Reporting | MED-EL [Internet]. Medel.com. 2019 [cited 7 March 2019]. Available from: http://www.medel.com/hearing-solutions/cochlearimplants/reliability
3. 2018 Global Implant Reliability Report. 027-N025-02 Rev B. Advanced Bionics AG and affiliates. 2018.
4. Compared to all currently available receiver stimulators available from Cochlear and other cochlear implant manufacturers. Based on published device specification information.

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Cochlear, Hear now. And always, Nucleus, Profile, and the elliptical logo are either trademarks or registered trademarks of Cochlear Limited.
© Cochlear Limited 2019. D1651459 V2 AUG19
 interdisciplinary
Irina-Maria
Gheorghiu1,
Paula Perlea2,
Claudiu-Gabriel
Ciolan3,
Loredana
Mitran4,
Mihai Mitran5,
Alexandru-Andrei
Iliescu6
1. Lecturer,
Department of Restorative
Odontotherapy,
Faculty of Dental Medicine,
“Carol Davila” University
of Medicine and Pharmacy,
Bucharest
2. Professor,
Department of Endodontics,
Faculty of Dental Medicine,
“Carol Davila” University
of Medicine and Pharmacy,
Bucharest
3. Dentist,
Private Dental Practice,
True Stomartists, Bucharest
3. MD, Department
of Otorhinolaryngology,
“Elias” University Emergency
Hospital, Bucharest
5. Lecturer, Department
of Obstetrics and Gynecology,
Faculty of Medicine,
“Carol Davila” University
of Medicine and Pharmacy,
Bucharest
6. Associate Professor,
Department of Oral
Rehabilitation,
Faculty of Dental Medicine,
University of Medicine
and Pharmacy of Craiova
Corresponding author:
Irina-Maria Gheorghiu
E-mail: igheorghiu@hotmail.com
36
The use of endodontic posts
in odontal restorations
of non-vital teeth
Abstract
In the clinical situations in which the restoration of massive
hard dental tissues loss is required, it is mandatory to
use additional retention systems that can ensure the
successful and long-term maintenance of the restoration.
In the case of non-vital teeth, endodontic posts are used
as additional retention systems. They can be custom
cast made (metallic) or prefabricated (prefabricated
metal posts or zirconia, ceramic, carbon or glass
fibers posts). The use of a certain type of prefabricated
endodontic post is the result of a completely and
rigorously evaluation of the present clinical case.
Keywords: non-vital tooth, endodontic post, post-retained
endodontic restoration
Submission date:
18.07.2019 Utilizarea pivoturilor endodontice în restaurările odontale armate pe dinţi
Acceptance date:
9.08.2019 devitali
Suggested citation for this article: Gheorghiu IM, Perlea P, Ciolan CG, Mitran L, Mitran M, Iliescu AA. The use of endodontic posts in odontal restorations of non-vital
teeth. ORL.ro. 2019;44(3):36-38.
Introduction
The coronal tissue loss involves the lack of a variable
amount of hard dental substance, of different etiology,
and which occurs in different degrees, from the shallow
enamel crack to an important, almost complete coro-
nary destruction when only the tooth root is present
on dental arch.
The amount of residual hard dental substance plays
an important role in the possibility of restoration of a
tooth. From this point of view, we must first analyze
whether the tooth can be restored or needs extraction.
When choosing the restoration method, we must take
into account multiple aspects of the clinical case, such as:
the position of the tooth on the dental arch, the value of
the occlusal forces, and the patient’s aesthetic expecta-
tions. Especially for young patients, it is normal to want
to limit the loss of hard dental tissue as much as possible
and to preserve the present state, but unfortunately this
is not always possible.
Endodontic posts
In clinical situations where restoration of coronary
dental tissue loss is on the borderline between direct
odontal and prosthetic restorative treatment, and
occlusal forces cannot be reduced or eliminated, it is
mandatory to use additional retention systems that can
Rezumat
În situaţiile clinice în care se impune restaurarea distrucţiilor
co­ro­nare masive, este obligatorie utilizarea mijloacelor
su­pli­men­tare de retenţie ce pot asigura succesul şi menți­
ne­rea restaurării pe termen lung. În cazul dinţilor devitali,
ca mijloace suplimentare de retenţie se utilizează pivoturile
endodontice. Acestea pot fi turnate (metalice) sau pre­fa­
bri­cate (pivoturi metalice prefabricate sau din zirconiu,
ce­ra­mi­că, fibre de carbon ori fibre de sticlă). Utilizarea unui
tip de pivot endodontic prefabricat sau a unuia turnat este
rezultatul evaluării complete şi riguroase a cazului clinic
respectiv.
Cuvinte-cheie: dinte devital, pivot endodontic, restaurare
odontală armată
ensure long-term obturation stability and success. In
the case of non-vital teeth, endodontic posts are used as
additional retention systems. Odontal restorations that
use them are called armed restorations or post-retained
endodontic restoration.
Special retention systems are used to improve the
retention of the cavities resulting from the evolution of
extensive carious processes. In situations where the loss
of a hard dental substance is of traumatic etiology, the
additional retention systems are, except for prosthetic
methods, the solution of choice for the retention of the
coronary restorative dental material. In the case of a
vital tooth that has a massive loss of dental tissue, spe-
cial retention systems help maintain the vitality of the
dental pulp, but the use of special retention systems is
also currently used in the case of endodontically treated
teeth(1).
Compared to the odontal restorations in vital teeth,
non-vital teeth presents specific aspects regarding coro-
nal rehabilitation. Massive tissue damage, as well as the
sacrifice of hard dental substance to obtain a proper
access for endodontic instrumentation may cause dif-
ficulties in ensuring retention of restorative dental ma-
terials(2). Some authors also consider that the fracture
resistance of endodontically treated teeth is significantly
lower than in vital teeth. Although it is a widely held
Year XII • No. 44 (3/2019)
opinion, there are controversies on this topic, multiple
laboratory studies have shown that fracture resistance
in non-vital and vital teeth is similar.
Additional retention systems used in non-vital teeth
are endodontic posts, which can be custom cast or pre-
fabricated. The current use of prefabricated posts is
associated with the coronary restoration of the dental
structure using the direct method, with modern adhe-
sive materials: composite resins or glass ionomer ce-
ment. Odontal restoration using endodontic posts is Figure 1. Custom cast metallic post in endodontically
indicated in situations when the coronal non-vital tooth treated tooth 26
structure is inadequate for the proper retention of a res-
toration(3). The root part of the endodontic post is fixed
and cemented into the prepared root canal (using curent
precedures with Gates Glidden or Paeso reamers) and the
supragingival portion of the posts ensures retention of
the restorative material.
nn Custom cast posts
The custom cast posts are made in the dental tech-
nique laboratory, following an impression of the root
canal preparation. The custom cast posts cast are still
valuable additional retention systems due to the preci-
sion with which they can be made and due to the resist-
ance to mechanical stresses in the oral cavity. The cast
posts acts like a post-core system. Their use tends to be
restricted because they have a number of disadvantages:
they require an important sacrifice of hard coronal tis-
sue, and they require time and precision to make them
since the dental technique laboratory is involved. Once
cemented, the treatment of possible apical lesions is al-
most impossible, due to their difficult removal(4).
The custom cast posts are made from metals that can
be easily processed, from noble or semi-noble metals,
or from silver or other special alloys (nickel-chromium,
cobalt-chromium, platinum-gold-palladium, stainless
steel), and will be subsequently covered with dental
crown.
nn Prefabricated posts
Prefabricated posts are widely used today, being avail-
able in a wide range of materials, shapes and sizes that
can be adapted to different clinical situations. Thus, the
prefabricated posts can be:
✔✔metal – stainless steel, titanium and its alloys,
platinum-gold-palladium, chromium-containing
alloy, surface-gold-plated copper-nickel alloy, co-
balt-molybdenum alloy. Figure 2. Custom cast metallic post for anterior tooth
✔✔non-metallic: ceramics, zirconium oxide, carbon,
quartz, glass fiber.
The prefabricated posts made from ceramic have the
same color as the dental tissues, they are biocompatible,
with a good radioopacity, but at the same time they are
expensive, difficult to be cut and cannot be bent. That’s
why they have a high risk of fracture under the action
of occlusal forces. They are also difficult to be removed
from the endodontic space when fractured. Compared
to the metal posts, the prefabricated carbon fiber ones
have a modulus of elasticity closer to that of the den-
tine, thus reducing the occlusal stress transmitted to Figure 3. Prefabricated fiber glass post in
the root(5). They are not corroded by the oral fluids and endodontically treated tooth 45

Year XII • No. 44 (3/2019)

37
interdisciplinary
Figure 4. Fiberglass posts
have a high wear resistance. The transfer of occlusal
stress to dentine can be reduced by introducing a more
elastic material, namely resin cements, which will act
as force breakers(6).
Regardless of the material from which they are made,
the prefabricated posts have multiple advantages: the
odontal restoration is done completely inside the dental
practice, without involving the dental technique labo-
ratory, thus saving time and money. They are easy and
very simple to be inserted into the prepared root canal,
and can be use in almost any clinical case, including
pluriradicular teeth(7). The prefabricated posts can be
1. Sulaiman AO, Shaba OP, Dosumu OO, Ajayi DM. Coronal tissue loss in
References
endodontically treated teeth. Afr J Med Med Sci. 2012 Dec; 41(4):437-44.
2. Peroz I, Blankenstein F, Naumann M. Restoring endodontically treated teeth
with post and cores – a review. Ouintessence Int. 2005; 36(9):737-46.
3. Lynch CD, Burke FM, Ni Riiordain R, Hannigan A. The influence of coronal
restoration type on the survival of endodontically treated teeth. Eur J
Prosthodont Restor Dent. 2004 Dec; 12(4):171-6.
4. Guruprasada LC. Restoration of fractured endodontically treated mandibular
first molar using custom made cast post and core. Med J Armed Forces India. 2015
Jul; 71(Suppl 1): S221–S223.
5. Atalay C, Yazici AR, Horuztepe A, Nagas E, Ertan A, Ozgunaltay G. Fracture
Resistance of Endodontically Treated Teeth Restored With Bulk Fill, Bulk Fill
38
removed when needed, especially those fixed by screw-
ing, easier than custom cast posts.
Despite the certain advantages of prefabricated posts,
unfortunately the limitations imposed in their use must
be taken into account: they do not always adapt perfectly
to the endodontic preparation such as the cast ones and
their coronal portion is not always sufficient to support
the volume of the required dental reconstruction(8).
The principles that govern the use of endodontic posts
in dental restorations in non-vital teeth are:
✔✔ Minimizing the sacrifice of a hard dental substance,
especially in the cervical region, in order to create
the encircling effect (“ferrule effect”).
✔✔ Use of adhesive techniques for both the coronal
and root tissues, to increase the strength of the
remaining dental structure and to improve the
retention and stability over time of the post-re-
stored tooth.
✔✔ Use of the materials with dentin-like physical pro-
perties, both for core and post.
The final restoration may be done directly in the den-
tal office or it may be a prosthetic restoration. If a direct
odontal coronal restoration is made, usually a prefabri-
cated endodontic post will be chosen. In restorations
using custom cast posts, it must be associated with a
microprothesis.
Conclusions
When choosing prefabricated endodontic post versus
custom cats post for a reinforced restoration, we must
assess rigorously all specific particularities of the clinical
case: the quantity of remaining hard substance, the in-
tensity of occlusal stress and the subsequent prosthetic
role of the respective tooth – these aspects are always
taken into account. Also, it is important to be able to
obtain a proper aesthetic aspect of the restoration, es-
pecially in the frontal area. n
Acknowledgements: All the authors have equal contri-
butions for this article.
Conflict of interests: The authors declare no con-
flict of interests.
Flowable, Fiber-reinforced, and Conventional Resin Composite. Oper Dent. 2016
Sep-Oct; 41(5):E131-E140.
6. Khan SIR, Anupama R, Deepalakshmi M, Kumar KS. Effect of two different types
of fibers on the fracture resistance of endodontically treated molars restored
with composite resin. The Journal of Adhesive Dentistry. 2013; 15(2):167–171.
7. Eliguzeloglu Dalkılıç E, Kazak M, Hisarbeyli D, Fildisi MA, Donmez N, Deniz Arısu
H. Can Fiber Application Affect the Fracture Strength of Endodontically Treated
Teeth Restored with a Low Viscosity Bulk-Fill Composite? Biomed Res Int. 2019
Jan 22; 2019:3126931.
8. Yasa B, Arslan H, Yasa E, Akcay M, Hatirli H. Effect of novel restorative materials
and retention slots on fracture resistance of endodontically-treated teeth. Acta
Odontol Scand. 2016; 74(2):96-102.
Year XII • No. 44 (3/2019)
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 atlas

Particular CT scan aspects

in ethmoid anatomy
Alexandra Abstract
Gheorghe1,
Silviu Crăc1, Anatomy based on imagistic findings is the key point on
which the understanding of normal and pathological
Alexandru structures is based. Nowadays, the conventional radiology
Panfiloiu1, has been replaced by CT imaging, the new gold standard
Vlad Budu1,2 for paranasal sinus pathology. Functional endoscopic
1. “Prof. Dr. Dorin Hociotă” sinus surgery is now the most popular technique used in
Institute of Phonoaudiology sinonasal pathology and it cannot be performed without
and Functional ENT Surgery,
Bucharest knowing the anatomic landmarks. A good understanding
of sinonasal anatomy and of anatomic variants provides
2. “Carol Davila” University
of Medicine and Pharmacy, a better surgical approach. The aim of this article is to
Bucharest focus on the landmarks found on CT scan in order to avoid
the complications of ethmoid sinus surgery. In this article,
we present the imagistic appearance on CT of ethmoid
landmarks beginning from anterior ethmoid (agger nasi,
uncinated process, ethmoidal bulla, middle turbinate) to
posterior ethmoid (ethmoidal cells, superior turbinate). We
also focused on the areas in which complications may occur
(lamina papyracea, anterior and posterior ethmoid artery,
cribriform plate). The reduction of complications incidence
begins with prevention by having a good preoperative
medical assessment. The surgeon needs to study the CT
imaging for each patient several times before the procedure.
Keywords: CT scan, ethmoid landmarks, endoscopic sinus
surgery
Rezumat
Anatomia ilustrată pe descoperirile imagistice reprezintă baza
înțelegerii structurilor normale și patologice rinosinuzale.
Ac­tual­mente, radiologia convențională a fost înlocuită de
ima­gis­tica CT, noul standard de aur în patologia sinusurilor
pa­ra­nazale. Chirurgia endoscopică sinuzală este în prezent
cel mai frecvent procedeu utilizat, putând fi efectuată doar
cu­nos­când reperele anatomice. O bună înțelegere a anatomiei
rino­sinuzale și a variantelor anatomice asigură realizarea
unei intervenții chirurgicale cu un grad scăzut de risc al com­
pli­cațiilor. Scopul acestui articol este să evidențieze reperele
ana­to­mice prezente pe imaginile CT. Aceste repere ajută la
evi­ta­rea complicațiilor în timpul intervențiilor chirurgicale de
tip endoscopic asupra etmoidului. În articol se evidențiază
as­pec­tul imagistic al reperelor anatomice etmoidale, începând
cu etmoidul anterior (celula agger nasi, procesul uncinat,
bula etmoidală, cornetul nazal mijlociu) spre cel posterior
(celulele etmodiale, cornetul nazal superior). De asemenea,
se pune accent și pe zonele la nivelul cărora sunt frecvent
de­scrise complicații intraoperatorii (lamina papiraceea, ar­
te­re­le etmoidale anterioară și posterioară, lama cribriformă).
Re­du­ce­rea incidenței complicațiilor are la bază o bună evaluare
pre­ope­ra­torie a pacientului. Chirurgul are responsabilitatea de
a studia imaginile CT pentru fiecare pacient, de mai multe ori,
înaintea procedurii chirurgicale.
Cuvinte-cheie: imagini CT, repere etmoidale, chirurgia
endoscopică rinosinuzală

Submission date:
21.08.2019 Aspecte particulare ale anatomiei etmoidale pe imagini CT
Acceptance date: Suggested citation for this article: Gheorghe A, Crăc S, Panfiloiu A, Budu V. Particular CT scan aspects in ethmoid anatomy. ORL.ro. 2019;44(3):40-45.
12.09.2019

Introduction
The CT scan represents the imaging investigation
of choice in case of sinonasal pathology, at the same
time the CT images revealing the anatomical variants
of this region.
The clinical picture according to the anatomical vari-
ants, from the level of the ethmoid, is represented by rhi-
nogenic headache, facial pressure, inefficient drainage,
or it can be asymptomatic, being discovered accidentally
after an imagistic investigation.
The ethmoid is a bone with a complex configuration,
which participates in forming the walls of the nasal cavity,
orbit and the floor of anterior cranial fossa. It is located
at the level of the ethmoidal incision of the frontal bone
and articulates with the sphenoid, maxillary, vomer, lac-
rimal, nasal, palatine, and quadrilateral cartilage. From
an anatomic point of view, the ethmoid consists of the
perpendicular blade, the horizontal blade and the two
lateral masses (the ethmoidal labyrinth) – Figure 1. Figure 1. CT aspect of ethmoidal labyrinth

40 Year XII • No. 44 (3/2019)

Figure 2. Agger nasi cell

Figure 4. The ethmoidal infundibulum

Figure 3. Pneumatized uncinated process Figure 5. Ethmoidal bulla

Figure 6. Types of concha bullosa (bulbous, lamellar, extensive)

Year XII • No. 44 (3/2019)

41
atlas
Figure 7. Paradoxical middle turbinate
Figure 8. Haller cell
The elements of the anterior ethmoid with anatomi-
cal variability must necessarily be followed and most of-
ten found on CT images. The anatomical variants of the
ethmoidal structures can cause changes in the normal
sinus physiology, which impose an appropriate therapeu-
tic behavior. We followed on the CT images different ana-
tomical structures of the anterior and posterior ethmoid.
1. Agger nasi cell
The agger nasi cell represents the anterosuperior cell of
the anterior ethmoid and is part of the uncinate cellular
system. When it exists, it represents an ethmoidal pneu-
matization, located at the level of the lacrimal bone, and
Figure 9. Keros classification (types I, II and III)
42
it is an important landmark in the approach of the frontal
sinus recess. On the CT image, it is identified superior by
the insertion of the middle turbinate and anterolateral and
inferior by the frontal sinus recess. A pneumatized agger
nasi cell can block the frontal sinus drainage (Figure 2).
2. Pneumatized uncinate process
The uncinate process (first lamella) is a thin ethmoi-
dal bone lamella, sagittal oriented, from anterior and
superior to posterior and inferior; it forms the anterior
limit of the semilunar hiatus. When the uncinate pro-
cess is hypertrophied and in contact with the mucosa of
the ethmoidal bulla or the middle turbinate, it blocks
the normal sinus drainage through the ethmoidal in-
fundibulum and may cause obstruction of osteomeatal
complex (OMC), resulting in altered ventilation of the
anterior sinuses of the face (Figure 3).
3. The ethmoidal infundibulum
The ethmoidal infundibulum represents the three-
dimensional space where we can find the ostium of the
maxillary sinus (most commonly). When the uncinate
process is inserted on the ethmoidal roof or middle
turbinate, the frontal sinus drains into the ethmoidal
infundibulum. The clinical picture of the obstruction of
the infundibulum is represented by the facial pressure
sensation and the lack of sinus ventilation (Figure 4).
4. Ethmoidal bulla
The ethmoidal bulla is a bony protrusion of the na-
sal lateral wall, known in the Anglo-Saxon literature as
“second lamella”. It represents an important landmark
in endoscopic sinus surgery, being the most consistently
pneumatized anterior ethmoidal cell. The lateral wall of
the ethmoidal bulla is always represented by lamina pa-
pyracea. On the coronal section it is visualized superior
by the ethmoidal infundibulum and posteriorly by the
hiatus semilunaris (Figure 5). 
The degree of pneumatization may vary: it extends
superiorly (ethmoidal roof), posteriorly (lamina basalis) or
laterally (lamina papyracea). In the case of a large bulla, it
will occupy the entire middle meatus, being in contact and
exerting pressure at the root of the middle nasal turbinate
(at the posterior opening of the ethmoidal  bulla  it rea­
ches directly into the posterior ethmoid) and the uncinate
Year XII • No. 44 (3/2019)
process (anterior) and frontal recess (superior) with the
disruption of drainage of the anterior sinuses of the face.
5. Concha bullosa
Concha bullosa represents the pneumatization of the
middle turbinate, sometimes causing changes to the sinus
physiology by obstructing the middle meatus and implicitly
the drainage pathways of the anterior paranasal sinuses.
The classification by Bolger highlights three types of
pneumatization: bulbous, lamellar, and extensive (Figure 6).
The clinical picture is dominated by persistent frontal
headache, facial pressure, chronic nasal obstruction and
hyposmia, symptomatology that directs patients to have
an imaging investigation.
6. Paradoxical middle turbinate
Typically, the middle turbinate is inserted superior on
the lateral nasal wall or ethmoid roof, having a descending
direction with the concavity located sideways. The para-
doxical middle turbinate is an anatomical entity in which
its concavity is oriented in direction of the nasal septum,
and the convex face blocks the drainage at the level of the
hiatus semilunaris. It is usually found bilateral (Figure 7).
The treatment in this type of anatomical variant is Figure 10. Asimmetry of the cribriform plate
surgical and consists in the resection of the concave part
of the middle turbinate with the positioning of the mid-
dle turbinate in the normal variant, allowing the drain-
age and ventilation of the anterior sinuses.
7. Haller cell
The maxillo-ethmoidal cell – orbito-ethmoidal cell or
Haller cell – develops by pneumatization from the level
of the anterior ethmoid towards the maxillary sinus and
always presents a common wall with the orbit.
It is located in the medial region of the maxillary si-
nus ceiling and the lowest portion of the lamina papyra-
cea, under the ethmoidal bulla, laterally by the uncinate
process. The Haller cell contributes to the narrowing
of the ethmoidal infundibulum and can compromise
the normal physiology of the maxillary sinus (Figure 8).
The diagnosis of Haller cell is established by CT ima­
ging, most of the time being a random breakthrough
following a regular sinonasal imaging investigation.
8. Ethmoidal roof
The ethmoidal bony wall of the skull base consists of Figure 11. Anterior ethmoidal artery
the cribriform plate and the ethmoidal roof and divides
the nasal cavity from the anterior and middle cerebral landmark in endoscopic sinus surgery. This artery can be
fossa. The Keros classification is an objective method in found in the posterior segment of the frontal recess and
measuring the depth of the olfactory fovea. In adults, has a path originating from the medial orbital wall to the
the recess is represented by a variable depression of the nasal septum. On CT scan, a small bulge in the lamina
cribriform plate which represents the thinnest structure papyracea (discontinuous appearance of the lamina) can
of the skull base, being roamed by the olfactory nerves be observed, which pinpoints the position of the anterior
and interconnecting arteries (Figure 9). ethmoidal artery (Figure 11).
CT scan is a standard method of identifying the height Injury inflicted upon this artery produces significant
of the ethmoidal roof. The surgeon must identify possi- bleeding and may cause orbital hematoma as a result
ble asymmetries of the olfactory fovea and assesses pre- of the retraction of the sectioned artery in the orbit,
operatively the risk of intracranial complications with requiring emergency orbital decompression.
the possibility of producing a bony or dural injury, with 10. Posterior ethmoidal artery
the occurrence of a cerebrospinal fluid leak (Figure 10). The anatomy of the ethmoidal arteries is important
9. Anterior ethmoidal artery for surgeons, as their injury can cause intraorbital he­
The anterior ethmoidal artery is a branch of the oph- mor­rhage and blindness due to a retrobulbar hematoma
thalmic artery and represents an important anatomical through optic nerve compression. Most studies to date

Year XII • No. 44 (3/2019)

43
atlas
Figure 12. Posterior ethmoidal artery
Figure 13. Pneumatized superior turbinate
focus on the anterior ethmoidal artery, and less on the
posterior (or middle) artery. After detaching from the
ophthalmic artery, the posterior ethmoidal artery pro-
vides vascular supply to the posterior ethmoidal cells,
the posterior nasal septum, and an intracranial branch
that is distributed to the dura mater.
The discovery of the posterior ethmoidal artery can
be achieved by following the CT scans where we can find
the posterior ethmoidal artery canal or the place where
it leaves the olfactory fossa in route to orbit crossing the
lamina papyracea (Figure 12).
11. Pneumatized superior turbinate
The superior turbinate is a part of the posterior ethmoid
that medially borders the superior meatus. Most of the
time, the superior turbinate is inserted on the ethmoidal
roof. In case of a pneumatized superior turbinate (superior
concha), the sphenoethmoidal recess gets blocked, leading
to inefficient sinus drainage (Figure 13).
This anatomical-clinical situation requires endoscopic
surgery with removal of the pneumatized superior turbinate.
44
Figure 14. Onodi cell
Some studies even show a causal relationship between the
rhinogenic headache and the presence of pneumatized su-
perior turbinate. Pneumatized superior turbinate is often
found bilaterally and can associate, besides headache, anos-
mia or hyposmia, by blocking the olfactory fovea.
12. Onodi cell
Onodi cell is a sphenoethmoidal air cell where we can
identify the optic nerve projection on its wall. It is very
important to identify any Onodi cell on a CT scan, be-
fore any endoscopic sinus surgery, because this air cell
can surpass laterally and superiorly the sphenoid. Once
the position of the Onodi cell is found in the CT scan,
it is important during endoscopic sinus surgery not to
confuse it with the sphenoid sinus, in order to avoid
intracranial complications (Figure 14).
Conclusions
Unsystematic headache, sometimes accompanied by
facial pressure, causes difficulties in diagnosis and treat-
ment. The endoscopic nasal exam and the computed
Year XII • No. 44 (3/2019)
tomography allow the proper diagnosis and therapeutic References
management to be established.
The anatomical variants of the ethmoidal structures 1. Dunnebier EA, Beek E, Pameijer F. Imaging for Otolaryngologists. Thieme
Publishing Group. 2011.
can cause changes in the drainage and ventilation of the 2. Shah G, Wesolowski J, Choi J. Head and Neck Imaging. Thieme Publishing
paranasal sinuses, and the treatment usually consists in Group. 2016.
3. Moedder U, Cohnen M, Anderson K, et al. Head and Neck (Direct Diagnosis in
surgical procedure. In order to perform an endoscopic Radiology). Thieme. 2007.
sinus surgery, it is necessary to study the sinonasal 4. Bradoo R. Anatomical Principles of Endoscopic Sinus Surgery. Taylor & Francis
Group. 2005.
anatomy through the CT investigation. n 5. Mancuso A, Hanafee W. Head and Neck Radiology. Lippincott Williams &
Wilkins. 2010.
Conflict of interests: The authors declare no con- 6. Hasso A. Diagnostic Imaging of the Head and Neck. Lippincott Williams &
Wilkins. 2012.
flict of interests.

Year XII • No. 44 (3/2019)

45
events
Primul Congres Naţional
al tinerei Societăţi Române
de Audiologie și Patologie
a Comunicării
Dragi colegi,
În perioada 12-14 septembrie 2019, am avut bucuria
să ne întâlnim într-un cadru academic și cultural special,
oferit de Palatul Culturii din Iași, cu ocazia Primului Con-
gres Național al tinerei Societăți Române de Audiologie și
Patologie a Comunicării (SRAPC), dedicat atât membrilor
săi, cât și tuturor colegilor interesați de domeniul audiologiei,
vestibulogiei și patologiei comunicării.
De la fondarea sa – în anul 2014 – și până în prezent,
SRAPC a desfășurat o activitate susținută, organizând nu-
meroase cursuri de specialitate în domeniul audiologiei și
vestibulogiei, participând la dezvoltarea asistenței medicale
pentru pacienții cu surditate, în colaborare cu Ministerul
Sănătății sau fiind partener activ al altor asociații negu-
vernamentale cu rol în dezvoltarea asistenței de specialitate
pentru copiii cu implant cohlear. SRAPC a devenit membră
afiliată a European Federation of Audiology Societies și
membră a International Society of Audiology din anul 2016.
Dezvoltarea în ritm alert a audiologiei pe plan global și
interesul tot mai mare al specialiștilor pentru performanță
profesională motivează organizarea de manifestări științifice
care să aibă un puternic accent pe sesiunile practice și cursurile
instrucționale. De asemenea, în România s-au deschis noi
oportunități, prin extinderea la scară națională a screeningu-
lui surdității la nou-născut, nevoia de specialiști în audiologie
devenind mai acută ca niciodată.
În acest sens, de-a lungul celor trei zile ale congresului
nostru, s-au desfășurat numeroase cursuri instrucționale,
conferințe, mese rotunde și prelegeri cu aplicații practice pe
teme de mare actualitate: identificarea precoce a pierderii au-
zului (screening și diagnostic) la nou-născuți, mijloace moder­
ne de diagnostic audiologic și vestibular, soluții de protezare
auditivă convențională, implantul cohlear în abilitarea/rea­bi­
li­tarea auditiv-verbală, genetica surdității, proteze implanta-
bile cu transmisie osoasă, electrofiziologie auditivă, audiolo-
gie pediatrică, patologia din spectrul neuropatiei auditive,
surditatea unilaterală, patologia retrocohleară, sindroamele
vertiginoase și tulburările de echilibru, declinul cognitiv și
demența în relație cu hipoacuzia, patologia auditivă centrală,
sindromul celei de-a treia ferestre și multe altele.
În numele comitetului director al SRAPC, aș vrea să le
mulțumesc în primul rând tuturor participanților, care, prin
interesul lor pentru audiologie, au conturat un prim eveni-
ment al societății demn de un pionierat promițător. De aseme-
nea, le mulțumim tuturor lectorilor invitați din străinătate,
personalități și profesioniști din domeniul audiologiei din Franța,
46
Brazilia, Germania, Polonia, Austria, Slovacia și Republica Mol-
dova, care ne-au făcut onoarea de a participa alături de lectorii
din țara noastră cu conferințe valoroase pe teme de mare interes,
contribuind la îmbogățirea experiențelor noastre și la actuali­
zarea metodelor de lucru pe care le vom aplica în viitor. Am fost
onorați să avem printre invitați personalități cunoscute din do-
meniul audiologiei, precum prof. dr. Hung Thai Van, președintele
în exercițiu al Societății Franceze de Audiologie şi research team
leader la Paris Hearing Institute, prof. dr. Edilene Boechat, Board
Director la International Society of Audiology (2012-2018), fost
preşedinte al Academiei Braziliene de Audiologie (2013-2015) și
next elected president al International Bureau for Audiophonolo-
gie (2020), și doamna Monica Jubran Chapchap, fost preşedinte
al Brazilian Association of Universal Newborn Hearing Screening
(1990-2013), Board Director al IERASG (International Evoked
Response Audiometry Study Group).
Acest prim congres a constituit și prima ocazie pentru
recunoașterea activității și profesionalismului unor personalități
din România, care au depus eforturi pentru dezvoltarea audiolo-
giei. Astfel, SRAPC i-a onorat cu diplome de excelență „pentru
contribuții deosebite aduse dezvoltării educației în domeniul au-
diologiei în România și pentru punerea în practică a celor mai noi
metode de diagnostic și tratament al surdității și tulburărilor de
echilibru” pe: prof. dr. Dan Mârțu, conf. dr. Mădălina Georgescu,
șef lucrări dr. Violeta Necula, ing. Ion Mareș, șef lucrări dr. Luigi
Mărceanu, dr. Alexandru Pascu, aud. Anca Modan, dr. Rodica
Mureșan, dr. Alexandra Neagu și șef lucrări dr. Simona Șerban.
Mulțumirile noastre se îndreaptă și către sponsorii con-
gresului, care au înțeles nevoia de dezvoltare a audiologiei în
România și care sperăm să ni se alăture și la edițiile viitoare.
Am încheiat acest congres mai bogați din punct de vedere pro-
fesional, dar și cu dorința de a repeta această experiență atât de
frumoasă în anul care vine. Societatea Română de Audiologie și
Patologie a Comunicării vă așteaptă la cursurile și congresele pe
care le organizează, încercând să vă ofere informații interesante
și valoroase din domeniul audiologiei și vestibulogiei.
Cu toate urările de bine,
Sebastian Cozma
Președinte al Societății Române
de Audiologie și Patologie a Comunicării,
Conferențiar la Disciplina ORL, Universitatea de Medicină
și Farmacie „Grigore T. Popa” Iași,
Coordonator Compartiment Audiologie și Vestibulogie –
Spitalul Clinic de Recuperare Iași,
Membru al Biroului Internațional de Audio-Fonologie
Year XII • No. 44 (3/2019)
 The First National Congress
of the young Romanian
Society of Audiology
and Communication Pathology
Dear colleagues,
Between the 12th and 14th of September 2019, we had the
joy of meeting in a special academic and cultural setting offered
by the Palace of Culture in Iași, on the occasion of the First
National Congress of the young Romanian Society of Audiology
and Communication Pathology (SRAPC) dedicated both to its
members, as well as to all colleagues interested in the field of
audiology, vestibulology and communication pathology.
Since its foundation – in 2014 – until now, SRAPC had a
sustained activity, organizing numerous specialized courses
in the field of audiology and vestibulology, participating in
the development of healthcare for patients with deafness in
collaboration with the Ministry of Health or being an active
partner of other non-governmental associations with a role in
developing specialized care for children with cochlear implant.
SRAPC has become an affiliated member of the European Fed-
eration of Audiology Societies and member of the International
Society of Audiology since 2016.
The rapid development of audiology on a global level and the
increasing interest of the specialists for professional performance
motivated the organization of scientific events that have a strong
emphasis on practical sessions and instructional courses. Also,
in Romania, new opportunities have been opened by expanding
the screening of deafness to newborns on a national scale, the
need for audiology specialists becoming more acute than ever.
In this regard, during the three days of our congress, there
were numerous instructional courses, conferences, round ta-
bles and lectures with practical applications on interesting
topics such as: the early identification of hearing loss (screen-
ing and diagnosis) in newborns, modern means of audiologi-
cal and vestibular diagnosis, conventional hearing prosthesis
solutions, cochlear implant in auditory-verbal rehabilitation,
genetics of deafness, implantable prostheses with bone trans-
mission, auditory electrophysiology, pediatric audiology, audi-
tory neuropathy spectrum disorders, retrocochlear pathology,
dizziness syndromes and balance disorders, cognitive decline
and dementia in relation to hearing loss, central auditory pa-
thology, third window syndrome, and many others.
On behalf of the SRAPC Steering Committee, I would like,
first of all, to thank all the participants who, through their
interest in audiology, outlined this first event of the society
worthy of a promising pioneering. We also thank all the in-
vited guest lecturers from abroad, personalities and audiology
professionals from France, Brazil, Germany, Poland, Austria,
Slovakia and the Republic of Moldova, who have made us the
honor of participating, along with lecturers from our country,
Year XII • No. 44 (3/2019)
at valuable conferences on topics of great interest, contributing
to the enrichment of our experiences and updating the working
methods that we will apply in the future. We were honored to
have well-known audiology personalities, such as Prof. Dr.
Hung Thai Van, the current president of the French Audiology
Society and research team leader at the Paris Hearing Insti-
tute, Prof. Dr. Edilene Boechat, Board Director of the Inter-
national Society of Audiology (2012-2018), former President
of the Brazilian Academy of Audiology (2013-2015) and next
elected President of the International Bureau for Audiophonol-
ogy (2020), and Monica Jubran Chapchap, former President
of the Brazilian Association of Universal Newborn Hearing
Screening (1990-2013) and Board Director of IERASG (Inter-
national Evoked Response Audiometry Study Group).
This first congress also constituted the first occasion for
the recognition of the activity and professionalism of some
personalities from Romania, who made efforts to develop au-
diology. Thus, SRAPC honored with diplomas of excellence
“for outstanding contributions to the development of audi-
ology education in Romania and the implementation of the
latest methods of diagnosis and treatment of deafness and
balance disorders” the following: Prof. Dr. Dan Mârțu, Conf.
Dr. Mădălina Georgescu, Lecturer Dr. Violeta Necula, eng. Ion
Mareș, Lecturer Dr. Luigi Mărceanu, Dr. Alexandru Pascu,
aud. Anca Modan, Dr. Rodica Mureșan, Dr. Alexandra Neagu,
and Lecturer Dr. Simona Șerban.
Our thanks go also to the sponsors of this congress, who
understood the need for the development of audiology in Ro-
mania, and we hope to join us in future editions.
We concluded this congress enriched professionally, but
also with the desire to repeat this beautiful experience next
year. The Romanian Society of Audiology and Communication
Pathology is waiting for you at the courses and congresses it
organizes, trying to give you interesting and valuable informa-
tion in the field of audiology and vestibulology.
With best wishes,
Sebastian Cozma, MD, PhD
President of Romanian Society of Audiology
and Communication Disorders,
Associate Professor, ENT Department of “Grigore T. Popa”
University of Medicine and Pharmacy, Iaşi, Romania,
Head of Audiology and Vestibulogy Department –
Clinical Rehabilitation Hospital Iaşi,
Member of the International Bureau of Audiophonology
(BIAP)
47
guidelines for article submission
Guidelines
for article
submission
PHOTO: SHUTTERSTOCK
Articles should have between 10000 and 40000 charac-
ters with spaces, and should be written with diacritical
marks in the Romanian language; titles should not be
very long.
The title, summary and keywords must be written in
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Sending the materials – full responsibility of the original
character of the materials sent for publication belongs
entirely to authors.
Publication or sending to be published – previously.
Articles published previously in other magazines will not
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n with a statement of the originality of the article,
signed by the corresponding author, that the paper hasn’t
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Guide to editing articles
Articles will be sent in Microsoft Word 2000 format, or
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(including the references) and they must be scientifically
and linguistically coherent. Articles must include: title
(in Romanian and English), subtitle, the complete name
of authors and their professional affiliation, abstract (in
Romanian and English), keywords (in Romanian and
48
English), full text, references, legend of figures and tabels.
The author(s) must assume responsibility that their paper
is complete and correct at the moment of submission,
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The Abstract must have approximately 10-15 lines, at
most 150 words length, and will include the objective/
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Figures must be sent separataley, not within the paper.
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must be numbered using Arabic numerals. Authors must
indicate in the full text where figures should be placed.
Figures legenda
We recommend that the results should be described
using international measure units and SI. Only interna-
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Year XII • No. 44 (3/2019)
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