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Paediatric nasal dermoids: Our experience
Dermoides nasales pediátricos: nuestra experiencia
Ravi Meher, Avani Jain
, Ishwar Singh, Nivea Singh, Raman Sharma
Corresponding author
Department of ENT, MAMC, New Delhi, India
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] ] ] 2 => array:2 [ "nombre" => "Ishwar" "apellidos" => "Singh" ] 3 => array:2 [ "nombre" => "Nivea" "apellidos" => "Singh" ] 4 => array:2 [ "nombre" => "Raman" "apellidos" => "Sharma" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of ENT, MAMC, New Delhi, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermoides nasales pediátricos: nuestra experiencia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 718 "Ancho" => 1250 "Tamanyo" => 93570 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph and CT scan showing nasoglabellar dermoid.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Midline congenital lesions of the nose are rare, occurring in 1:20,000–40,000 births.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> These include nasal dermoids, nasal gliomas and encephaloceles. Among these, nasal dermoid are the most frequently encountered. Nasal dermoid is a midline anomaly that can present as a cyst, sinus or fistula and may have an intracranial extension.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> The pathogenesis involves incomplete obliteration of the neuroectoderm during development of the frontonasal process.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> It is lined by stratified squamous epithelium and contains both ectodermal and mesodermal elements, including adnexal structures and sebaceous glands. It may appear anywhere from the glabella, along the bridge of the nose, to the base of the columella. Patients may present with facial swelling or infection. There may be intermittent discharge of sebaceous material or pus, abscess, osteomyelitis, broadening of the nasal root or bridge and/or intracranial complications. Timely diagnosis and appropriate surgical management are essential to avoid complications and prevent progressive enlargement. Complete excision of nasal dermoid cyst sinus, regardless of its extension, is essential to prevent recurrence, infection, meningitis and intracranial abscess formation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This retrospective study evaluates our experience of the clinical presentation, imaging and surgical findings of nasal dermoids. The contribution of computed tomography (CT) and magnetic resonance imaging (MRI) in preoperative surgical planning was also studied. Given the rarity of these lesions, large studies are difficult to acquire. Also, most of the studies reported till date are from the Western world and there is lack of data from developing countries like India.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">A retrospective analysis of patients admitted for the treatment of nasal dermoid between 2012 and 2017 was done. A total of 10 patients were included in the study. We reviewed the patient presentation, preoperative imaging (CT/MRI), surgical approach, intraoperative findings, complications and recurrence. Imaging findings were compared with intraoperative surgical findings to evaluate their accuracy to diagnose intracranial extension. The diagnosis in each case was confirmed by surgical pathology.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 10 patients were included in this study, 6 were males and 4 were females (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The age at time of presentation ranged from 4 to 18 years of age, with an average of 10.2 years. There was no significant family history or associated craniofacial anomaly in any of the patients. One patient had an associated branchial sinus. There was no history of intracranial infections or meningitis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Three patients presented with a mass located on the nasal dorsum, 1 had a nasoglabellar mass (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), 2 patients has a mass located on nasal dorsum with visible sinus, and 4 patients presented with a sinus on the nasal dorsum (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) out of which 1 patient had a tuft of hair (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Four patients presented with asymptomatic masses and sought consultation for cosmetic purposes, whereas the remaining six patients presented due to recurrent infections and discharging sinuses, as well as cosmesis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">All the patients underwent preoperative imaging to determine the extent of lesion and rule of intracranial extension. CT scan was done in all the cases. As per the CT scan findings, there was no intracranial extension in 9 patients, and was non-diagnostic in one patient. Both CT and MRI were done in 2 patients, with no evidence of intracranial extension. No patients were found to have associated intracranial anomaly on CT and MRI scan. Surgical and radiological findings were concordant in 8 patients (80%). In one patient, the intracranial extension was not noted on CT but was evident intraoperatively as the sinus extended up to but did not breach the dura. There was a defect in the floor of the anterior cranial fossa but dura was intact. In another patient, intraosseous extension of the sinus tract was not noted on CT but was evident intraoperatively.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The surgical approach and findings of each of the patients is mentioned in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The patients were classified according to Hartley et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> into superficial, intraosseous, intracranial extradural and intracranial intradural. In all cases, the diagnosis of nasal dermoid sinus cyst was confirmed pathologically. There were no major intraoperative or postoperative complications. All the patients were followed up for one year, with no evidence of recurrence or altered nasal bone development and significant deformity during the follow up period.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Nasal dermoid sinus cysts are rare congenital anomalies, that are commonly present at birth or soon after. They have a male predominance.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> These lesions are occasionally known to be familial.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7,8</span></a> In this series, none of our patients had a positive family history or other associated craniofacial anomalies. One patient had an associated branchial sinus.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The average age at time of presentation in our study was 10.2 years. This was much higher as compared other studies, Bloom et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> – 3 months, El-fattah et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> – 2.5 years, Hartley et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> – 29 months, Herrington et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> – 3.1 years, Ortlip et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> – 1 year. The possible causes in a developing country, like ours, could be low socioeconomic status, illiteracy, large families with single earning member and no access to health care facility in villages. These factors lead to a delay in seeking treatment.</p><p id="par0050" class="elsevierStylePara elsevierViewall">These lesions usually present as a midline swelling on the nasal dorsum and may be associated with a sinus opening and intermittent discharge of sebaceous material and recurrent infection. Hair may emerge from the sinus opening and is considered pathognomonic for nasal dermoid. Masses are often present at birth or soon after, progressively increase in size, with or without recurrent infections. Patients may present with a history of recurrent infections or due to cosmetic concerns. In this study, the main reason for consultation was for cosmesis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Intracranial extension has been well described in literature, with most series reporting a rate between 4 and 57%.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6,13</span></a> All patients with nasal dermoids should be considered as having intracranial extension, unless proved otherwise.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Intracranial extension may be extradural or intradural. Fortunately, most of the patients with intracranial extension are extradural. The intracranial tract traverses the foramen caecum or cribriform plate to reach the anterior skull base and adhere to the falx cerebri extradurally. Intracranial infection in the form of meningitis, cavernous sinus thrombosis and periorbital cellulitis has been reported following nasal dermoid infection, but this was not seen in our series.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">14,15</span></a> 4 of our patients had abscess formation and secondary fistula formation at the nasal dorsum.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Preoperative imaging is essential to confirm the diagnosis and to rule out other intracranial anomalies. It also helps to determine the extent of the lesion and intracranial extension, thereby facilitating complete surgical resection. Preoperative imaging includes CT, and complementary MRI should be considered in suspected intracranial extension. However, some authors consider that MRI alone is the most accurate and cost-effective means of evaluating nasal dermoids. The established criteria for intracranial extension on CT include a bifid crista galli process and enlargement of the foramen caecum. The interpretation of CT in young children may be hindered because the lamina perpendicularis of the ethmoid bone and the crista galli frequently are not ossified, which can be mistaken for intracranial extension. Positive predictive values reported in CT and MRI are 85.7% and 100%, respectively. Negative predictive values have been estimated at 50% for CT and MRI. In our study, CT was done in all the patients and both CT and MRI was only done in two patients. Due to the higher cost of MRI, the patients could not afford the scan.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Complete surgical excision of nasal dermoid cyst and any associated sinus tract is essential for cure. Any residual ectodermal elements may result in a high rate of recurrence and complications. Recurrence has been estimated at 50–100% if resection is incomplete. As proposed by Pollock, the surgical approach chosen to excise a nasal dermoid should adhere to four principles: should allow adequate exposure to the mass and associated sinus tract, should allow access to the skull base, should provide exposure for reconstruction of the nasal dorsum, and should result in a cosmetically acceptable scar. Surgical approach depends on the locations and extent of the lesion, ranging from local excision to a combined intracranial–extracranial approach. The patients’ cosmetic concerns must also be taken into account. Multiple approaches have been described, including vertical incision, transverse incision, lateral rhinotomy, medial paracanthal, U-shaped dorsal incision, external rhinoplasty, degloving procedure, transglabellar incision, brow incision, and bicoronal incision. Traditionally, for removal of intracranial extension, bifrontally craniotomy was done. This was associated with a high morbidity and high complication rate. The complications may include meningitis, hyposmia, CSF leak, damage to frontal and sagittal sinus, epilepsy, frontal bone osteomyelitis and occasionally, intracerebral hemorrhage, cerebral edema and memory loss. In recent years, however, both subcranial and endoscopic approaches have been proposed, in order to reduce the morbidity. Kellman et al. described transglabellar subcranial approach for nasal dermoids with intracranial extension, with no recurrence or negative effect on craniofacial growth. Weiss et al. have described successful transnasal endoscopic excision of nasal dermoid with intracranial extension, without need for craniotomy. This technique was not recommended for dermoids extending into or beyond falx cerebri. Recently, however, successful endoscopic resection of intradural intracranial nasal dermoid have been reported. Schuster et al. reported successful endoscopic removal of two intracranial dermoids extending to anterior frontal lobe, with a pedicled nasoseptal flap to close the skull base defect. Duz et al. described endoscopic excision of a cystic lesion located in the anterior subfrontal region. The transnasal approach meets all the criteria recommended by Pollock for resection of intracranial extension of nasal dermoid, with no external scar. Also, the morbidity and complications associated with frontal craniotomy are minimized, thereby facilitating early post operative recovery and shorter hospital stay.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In this series, the lesions were predominantly superficial and involved local excision and direct closure. The cases reported in this series have been classified according to the deep extent of the lesion (Hartley et al.), which allows precise surgical planning. The most common superficial lesions remain within the soft tissue and were easily excised. Intraosseous lesions required drilling of nasal or frontal bone for complete excision. Intracranial extradural lesion was excised by Lynch incision and limited frontonasal craniotomy and was peeled off the dura. This avoided any major complications associated with bifrontal craniotomy. There were no intraoperative or post operative complications in our study.</p><p id="par0075" class="elsevierStylePara elsevierViewall">This study has several limitations. First, this is a retrospective study with a small sample number of patients. Also, most of our patients, belonging to lower socioeconomic strata, could not afford complete pre operative imaging. However, given the rarity of these lesions, large studies are difficult to acquire. Also, most of the studies reported till date are from the Western countries, and there is lack of data from developing countries like ours.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nasal dermoids are uncommon congenital midline lesions presenting with nasal swelling or sinus tract opening on the skin. Preoperative imaging (CT and MRI) is essential to rule out intracranial extension and other associated anomalies. The new classification proposed by Hartley et al., is a useful system for describing such lesions and allows precise surgical planning. When identified, early and complete surgical excision is mandatory to reduce the risk or recurrent infections, deformity and recurrence.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Source of funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1308875" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1208374" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1308874" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1208373" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Source of funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-25" "fechaAceptado" => "2018-12-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1208374" "palabras" => array:3 [ 0 => "Nasal dermoid" 1 => "Congenital nasal lesion" 2 => "Pediatric" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1208373" "palabras" => array:3 [ 0 => "Dermoide nasal" 1 => "Lesión nasal congénita" 2 => "Pediátrico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nasal dermoids are rare developmental anomalies seen in children. This study reports our experience in a developing country of the clinical and radiological findings as well as the management of nasal dermoids.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective analysis was performed, from 2012 to 2017, for 10 patients admitted for the treatment of nasal dermoids at a tertiary care center. The clinical presentation, preoperative imaging (CT/MRI), surgical approach, intraoperative findings, complications and recurrence were reviewed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ten patients were included in this study, 6 males and 4 females, with an average age of 10.2 years at the time of presentation. Three patients presented with a mass located on the nasal dorsum, 1 had a nasoglabellar mass, 2 patients had a mass located on the nasal dorsum with visible sinus, and 4 patients presented with a sinus on the nasal dorsum, in which 1 patient had a tuft of hair. CT was performed in all the cases. It was not suggestive of intracranial extension in 9 patients, and was non-diagnostic in one patient. Both CT and MRI were performed on 2 patients, with no evidence of intracranial extension. Surgical and radiological findings were concordant in 8 patients (80%).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nasal dermoids require preoperative imaging and precise surgical planning to achieve complete removal.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los dermoides nasales son anomalías del desarrollo poco frecuentes que se observan en niños. Este estudio informa de nuestra experiencia, en un país en desarrollo, de los hallazgos clínicos y radiológicos, así como el manejo de los dermoides nasales.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un análisis retrospectivo, desde 2012-2017, para 10 pacientes ingresados ??para el tratamiento de dermoide nasal en un instituto de nivel terciario. Se revisaron la presentación clínica, las imágenes preoperatorias (TC/RM), el abordaje quirúrgico, los hallazgos intraoperatorios, las complicaciones y la recurrencia.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 10 pacientes en este estudio, 6 varones y 4 mujeres, con una edad promedio de 10,2 años en el momento de la presentación. Tres pacientes presentaban una masa localizada en el dorso nasal, uno tenía una masa nasoglabellar, 2 pacientes presentaban una masa localizada en el dorso nasal con seno visible y 4 pacientes presentaban un seno en el dorso nasal, de los cuales un paciente tenía un mechón de pelo. La TC se realizó en todos los casos. No sugirió una extensión intracraneal en 9 pacientes y no fue diagnóstico en un paciente. Tanto la TC como la RM se realizaron en 2 pacientes, sin evidencia de extensión intracraneal. Los hallazgos quirúrgicos y radiológicos fueron concordantes en 8 pacientes (80%).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los dermoides nasales requieren imágenes preoperatorias y una planificación quirúrgica precisa para lograr una extracción completa.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 718 "Ancho" => 1250 "Tamanyo" => 93570 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph and CT scan showing nasoglabellar dermoid.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 639 "Ancho" => 1250 "Tamanyo" => 122681 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) Clinical photograph of discharging sinus nasal dorsum, (b) MRI showing intraosseous extension of sinus.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1145 "Ancho" => 650 "Tamanyo" => 98139 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph of nasal dermoid sinus with tuft of hair.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">S. no. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age/sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Presentation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Imaging \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgical approach \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgical findings \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classification (Bradley) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharging sinus nasal dorsum with tuft of hair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sinus tract with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass on nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2<span class="elsevierStyleHsp" style=""></span>cm mass with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharging sinus nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT & MRI; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2<span class="elsevierStyleHsp" style=""></span>cm sinus tract with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intraosseous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass with pit on nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5<span class="elsevierStyleHsp" style=""></span>cm mass with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nasoglabellar mass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lynch incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>cm mass with intracranial extradural extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intracranial extradural \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharging sinus nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sinus tract with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intraosseous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass on nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>cm mass with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharging sinus nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sinus tract with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intraosseous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass with pit on nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>cm mass with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharging sinus nasal dorsum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT & MRI; no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertical incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>cm sinus tract with no intracranial extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intraosseous \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2242935.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Characteristics of nasal dermoid patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Midline cysts of the nasal dorsum: embryologic origin and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.W. 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