First-trimester assessment of the nasal bones using the retronasal triangle view: a 3-dimensional sonographic study

The purpose of this study was to evaluate a new sonographic technique for identifying the nasal bones using the retronasal triangle view, ie, the coronal plane at which the palate and frontal processes of the maxilla are simultaneously visualized.

Three-dimensional (3D) volumes were acquired from women undergoing first-trimester sonographic screening for aneuploidy by 2 accredited operators. Those data sets in which the fetal face was clearly identified were selected for offline analysis by 2 other observers who were unaware of the sonographic or clinical findings. The nasal bones were classified as both present, only 1 present (right or left), or absent according to the presence or absence of 2 small paired echogenic linear structures at the upper tip of the retronasal triangle as determined by 3D navigation in the coronal plane and compared to those findings obtained by 3D navigation in the sagittal plane. Additional 3D data sets involving a subset of 4 first-trimester fetuses with trisomy 21 and absent nasal bones were also analyzed retrospectively and included randomly in the study group.

A total of 110 3D data sets were analyzed, of which 86% were obtained transabdominally and 14% transvaginally. The quality of nasal bone identification was classified subjectively by the observers as good in 67% of cases, fair in 29%, and poor in 4%. The nasal bones were classified as at least 1 present in 106 of the cases (96%) and absent in 4 (4%), with complete agreement between observers in both the sagittal and coronal planes (κ = 1). Discrimination between the right and left nasal bones was possible in 89% and 93% for observer A and in 96% and 96% for observer B by assessing the sagittal and coronal views, respectively (right nasal bone: κ = 0.90 [95% confidence interval (CI), 0.79-1]; left nasal bone: κ = 0.85 [95% CI, 0.60-0.99]). The nasal bones were not identified at the level of the retronasal triangle view in any of the fetuses with trisomy 21 and absent nasal bones.

This study shows that the nasal bones can be confidently identified as paired echogenic structures located at the upper tip of the retronasal triangle. This coronal view of the fetal face offers the possibility of screening for the presence or absence of the nasal bones in the first trimester, especially when the standard midsagittal views of the fetal face are suboptimal because of fetal or maternal factors. Because both nasal bones can be evaluated simultaneously in the coronal plane, the retronasal triangle view may be advantageous over the conventional midsagittal view assessment, in which only 1 of the 2 nasal bones is evaluated.