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

Outcome of Concurrent Septorhinoplasty and Functional Endoscopic Sinus Surgery (FESS) in Patients with Sinusitis and Nasal Deformity: A Retrospective Study and Review of Literature

Patients with deformed external noses and deviated nasal septum also have lateral wall deformities compromising the osteomeatal complex leading on to sinusitis. These patients will need septorhinoplasty along with functional endoscopic sinus surgery (FESS) to facilitate proper drainage of sinuses. The two main risks of combined procedure are firstly the risk of infection if done in infected sinusitis and secondly, the fear of collapse of nasal bone and the frontal process of the maxilla if medial and lateral osteotomies are done after extensive ethmoidectomy for extensive sinus disease. Our objective was to study the outcomes of combined septorhinoplasty with functional endoscopic sinus surgery in patients having sinusitis along with nasal deformity. In this retrospective study we describe the outcomes of patients who have undergone combined FESS + Rhinoplasty. We controlled the sinus infection and avoided extensive polyposis for combined procedure. We found that nasal block, facial pain, anosmia, rhinorrhea improved in all the patients There was a complete resolution of symptoms in the group. Thus, in combined surgery, we could simultaneously get a good functional airway, solve the sinus complaints and improve the nasal aesthetics satisfactorily. The patients were subjected to SNOT scale in 2023 and average score of SNOT score was found as 11 at an average postop followup period of 14 Years post op. We found that combined Rhinoplasty and Functional Endoscopic Sinus Surgery for patients having nasal deformity with chronic Rhinosinusitis can be performed safely and effectively. Simultaneously harvested septal cartilage could be used judiciously for meticulous reconstruction. It, avoided the extra cost and patient's time of two staged partial surgery.

Outcomes of Concurrent Functional Endoscopic Sinus Surgery and Rhinoplasty: A Meta-analysis

INTRODUCTION

Chronic rhinosinusitis (CRS) and functional nasal airway obstruction are common but distinct medical problems which affect quality of life. In certain instances, patients often benefit from concomitant functional septorhinoplasty, or elect for cosmetic rhinoplasty, in addition to functional endoscopic sinus surgery (FESS) and prefer combining procedures. Determining outcomes of combined surgery is important when discussing risks and benefits with patients.

METHODS

A thorough literature search of articles published in PubMed, Ovid MEDLINE, and Cochrane databases. Patients were categorized as either having FESS or rhinoplasty alone or combined. Binary random-effects models were applied to calculate odds ratios (ORs) for outcomes including complications, recurrence, and satisfaction.

RESULTS

Of the 55 screened articles, 6 were included in the analysis, and of these, 6 (405 patients), 2 (90 patients), 4 (290 patients), and 3 (190 patients) provided data for postoperative complications, recurrence of CRS symptoms, revision rates, and patient satisfaction, respectively. Major complications were observed in 11 (5.8%) total combined cases, 0 (0%) FESS cases, and 6 (3.5%) rhinoplasty cases with no statistical difference between combined cases and rhinoplasties (OR 1.37, 95% CI 0.45-4.16, p = 0.58). Recurrence of CRS symptoms was noted in 35.6% combined cases and 28.9% FESS cases (OR 1.42, 95% CI 0.55-3.64, p = 0.47). There was no observed difference in revision rates between combined and isolated rhinoplasties (OR 1.00, 95% CI 0.43-2.32, p = 1). Lastly, 91.6% of patients were satisfied with results of combined cases compared to 87.4% of patients in standalone cases (OR 1.57, 95% CI 0.61-4.03, p = 0.35).

CONCLUSION

Aggregate evidence demonstrates similar risk in complication rates in combined surgical cases compared to stand-alone rhinoplasty. There appears to be no significant difference in recurrence of symptoms, revision rates or patient satisfaction.

Analysis of the operative utilization of concurrent rhinoplasty and endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Cross-sectional analysis.

METHODS

Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared.

RESULTS

Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes).

CONCLUSIONS

RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:E311-E319, 2020.

Contemporary considerations in concurrent endoscopic sinus surgery and rhinoplasty

PURPOSE OF REVIEW

Characterize indications, perioperative considerations, clinical outcomes and complications for concurrent endoscopic sinus surgery (ESS) and rhinoplasty.

RECENT FINDINGS

Chronic rhinosinusitis and septal deviation with or without inferior turbinate hypertrophy independently impair patient-reported quality of life. Guidelines implore surgeons to include endoscopy to accurately evaluate patient symptoms. Complication rates parallel those of either surgery (ESS and rhinoplasty) alone and are not increased when performed concurrently. Operative time is generally longer for joint surgeries. Patient satisfaction rates are high.

SUMMARY

Concurrent functional and/or cosmetic rhinoplasty and ESS is a safe endeavor to perform in a single operative setting and most outcomes data suggest excellent patient outcomes. Additional studies that include patient-reported outcome measures are needed.

Endoscopic Sinus Surgery Associated with Rhinoseptoplasty: A Case-control Study

Objective

To examine the difference between outcomes in the administration of concurrent endoscopic sinus surgery (ESS), septoplasty (SP), and rhinoplasty (RP) and concurrent ESS and SP in 1 single surgical session.

Methods

Patients who underwent concurrent ESS and SP from September 2004 to July 2015 were identified. Furthermore, patients among them who underwent functional primary RP were selected. Subjects who had been administered concurrent ESS, SP, and RP (primary RP) were matched for sex, age, sinonasal surgical procedures for treatment of chronic rhinosinusitis with patients underwent concurrent ESS and SP, used as control subjects. A literature review was performed to find previous articles describing results of concurrent procedures among ESS, SP, and RP.

Results

Twenty subjects, who underwent concurrent ESS, SP, and RP, were compared with a matched control group made of 20 patients who underwent concurrent ESS and SP, evaluating different postoperative outcomes (postoperative complications, postoperative improvement of respiratory symptoms, persistence of chronic rhinosinusitis symptoms 6 months to 1 year postoperative, need of revision surgery, satisfaction of the patient). Obtained P values showed that there was no statistically significant difference (P > 0.05) as regards the different outcomes, except for postoperative complications, increased because of the invasiveness proper of RP (P < 0.05).

Conclusions

Therefore, execution of concurrent ESS, SP, and RP seems to be safe and effective, and additional RP does not modify postoperative outcomes of concurrent ESS and SP except for a little increase of postoperative complications, even if most of them had low impact on result of procedures.

The effects of endoscopic sinus surgery on the postoperative outcomes of open rhinoplasty

OBJECTIVE

Several studies have advocated concurrent endoscopic sinus surgery and rhinoplasty. However, concerns about increased surgical risk, complications, and unsuccessful cosmetic outcomes following the concurrent procedures have been reported. The aim of this study was to investigate the overall safety of concurrent endoscopic sinus surgery and rhinoplasty and to specifically examine the effect of endoscopic sinus surgery on cosmetic outcomes.

METHODS

We retrospectively reviewed 57 patients who underwent concurrent open rhinoplasty and endoscopic sinus surgery (ESS). We then selected a control group of patients, who underwent rhinoplasty only and were matched with a study group for age, sex, external nose deformity, and implant graft material. The postoperative outcomes of the 2 groups were compared.

RESULTS

Fifty-seven patients underwent concurrent open rhinoplasty and ESS. Postoperative assessment showed that a successful outcome was achieved in 82.5% of the patients who underwent concurrent procedures and in 87.7% of the patients who underwent rhinoplasty only (P = .56). The rate of revision due to a dissatisfied outcome was 5 patients (8.7%) in the concurrent surgery group and 3 patients (5.3%) in the rhinoplasty-only group (P = .36). Minor complications occurred in 6 patients (10.5%) from the group who underwent the concurrent procedures and 5 patients (8.8%) from the rhinoplasty-only group (P = .76).

CONCLUSION

Combined rhinoplasty and endoscopic sinus surgery achieves a similar aesthetic outcome to rhinoplasty only, with no significant increase in rates of revision or complication.

Concurrent functional endoscopic sinus surgery and septorhinoplasty: using evidence to make clinical decisions

BACKGROUND

Concurrent septorhinoplasty (SRP) and functional endoscopic sinus surgery (FESS) has been a controversial topic in the literature over the last decade. Warnings and admonitions about the risks of performing these procedures together in a single surgery are both published and voiced at national meetings. Although pros and cons have been discussed in the literature, there have been no guidelines published based solely on a review of the level of evidence.

METHODS

A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were an adult population >18 years old, description or implication of study design available, concurrent FESS and SRP performed without additional procedures, and report of complications included in the study.

RESULTS

We identified and evaluated the literature meeting those criteria: 11 retrospective studies. The literature was reviewed for both quality of research design as well as benefit and harm of the proposed interventions.

CONCLUSION

If a patient is in need of FESS and SRP, either for functional or cosmetic reasons, and is found on the risk matrix to either have low or moderate risk, that patient is a good candidate for a concurrent procedure. If the patient is found to have higher risk, it is not an absolute contraindication, but the surgeon must use best clinical judgment when deciding to move forward and must counsel the patient preoperatively about possible increased risks.

Benefit of combined endoscopic sinus surgery and aesthetic rhinoplasty

INTRODUCTION

Rhinoplasty is one of the most commonly performed aesthetic procedures today. Although nasal airway obstruction is frequently treated concomitantly with the aesthetic procedure, chronic sinusitis has typically postponed until full resolution of inflammatory symptoms.

AIM OF THE STUDY

To investigate the feasibility of combining FESS with septorhinoplasty by measuring different outcomes including operative time, blood loss, post-operative edema of the upper and lower eyelids, periorbital ecchymosis, patient discomfort and complication rates.

PATIENTS AND METHODS

The study included 20 patients with deformed nose associated with chronic rhinosinusitis (CRS) not responding to medical treatment for at least 3 continuous months, irrespective to sex, of ages 20-60, and without any systemic diseases (study group), and 20 patients with deformed nose without any sinus problems (control group).

RESULTS

There was no significant difference between the two groups in the different measured outcomes (P>0.05) except for the operative time which was significantly less in the control group (P<0.05).

CONCLUSION

Concurrent rhinoplasty and endoscopic sinus surgery may be performed safely and effectively with minimal risks. Proper patient selection and sound intraoperative judgment can avoid potential complications.

Rhinoplasty and functional endoscopic sinus surgery

An increasing number of patients are opting for combining sinus surgery and cosmetic rhinoplasty. The author has been performing rhinoplasty with FESS since April of 1990. The technique and equipment used in early cases is much different than that used in more recent surgeries. Specific advances include high definition monitor, intraoperative navigation system, and powered dissecting instruments. The benefits of these advances are illustrated by a review of the more recent cases performed by the author. Combined rhinoplasty and FESS can be performed with good results (functional and cosmetic) and minimal complications. Advances in sinus surgery technique and equipment have made the procedure safer, faster, more precise, and more comfortable.

Triological thesis: concurrent endoscopic sinus surgery and cosmetic rhinoplasty: rationale, risks, rewards, and reality

OBJECTIVES/HYPOTHESIS

To examine the effect of concurrent endoscopic sinus surgery (ESS) on the postoperative course of cosmetic rhinoplasty (CR), identify any specific contraindications, and to develop more useful treatment regimen in patients undergoing concurrent ESS and CR.

STUDY DESIGN

Retrospective case-control study.

METHODS

Consecutive patients undergoing CR (performed by the principal investigator (PI) in a tertiary care academic practice) at the same operative setting as ESS from June 2004-June 2007 were identified. Additionally, patients undergoing CR (also by the PI) without ESS over the same time period (matched for gender, age, and rhinoplasty approach and techniques) were identified and used as control subjects. The office and hospital charts of these patients were reviewed for details of pre-, intra-, peri-, and postoperative care, preoperative CT scans as well as for patient and physician observations. Specifically noted were details regarding the type of cosmetic changes sought, course of symptoms of chronic sinusitis, prior treatment, surgical techniques used for both ESS and CR, and postoperative treatment with antibiotics and corticosteroids. Additionally, a literature review of articles describing concurrent CR and ESS was performed.

RESULTS

Thirteen patients were identified who underwent ESS at the same time as CR. There were no cases of cerebrospinal fluid leak, epistaxis, orbital complications, septal perforation, cellulitis or saddle nose deformity. No correlation was found between sinus surgery performed and need for revision surgery (CR or ESS) or postoperative infections. However, the time to patient reported resolution of postoperative nasal swelling was significantly higher in patients undergoing concurrent ESS/CR compared to CR only (dorsal swelling: 9.62 +/- 6.18 (ESS/CR) vs. 5.85 +/- 1.95 (CR) weeks, P = .0469; nasal tip swelling: 19.31 +/- 13.02 (ESS/CR) vs. 10.38 +/- 2.96 (CR) weeks, P = .0240, unpaired t test). The same relation held true for doctor noted postoperative edema (nasal dorsal edema: 10.62 +/- 7.32 (ESS/CR) vs. 6.31 +/- 2.72 (CR) weeks, P = .0582; nasal tip edema: 21.46 +/- 15.66 (ESS/CR) vs. 12.23 +/- 4.10 (CR) weeks, P = .0508, unpaired t test). Among patients who underwent concurrent ESS and CR, this time was highly correlated with the severity of sinus disease on preoperative CT scanning (r(2) = 0.8573, P < .0001). A greater need for postoperative corticosteroid injections in the ESS/CR group was suggestive but not statistically significant (30.8% vs. 0%, P = .0957).

CONCLUSIONS

While our data supports concurrent ESS and CR as safe, our findings suggest that the presence and treatment of concurrent sinonasal disease prolongs the patients' recovery from CR. This may be due to the effects of sinus pathology and manipulation of sinonasal venous and lymphatic drainage patterns or could be due to subclinical infectious soiling of rhinoplasty tissue planes. We recommend a two-team approach to promote excellent surgical technique, avoid surgeon fatigue, and enhance patient care. We recommend adequate medical management of chronic sinusitis prior to surgery, pre, intra and postoperative antibiotic coverage, appropriate postoperative sinus toilet beginning 1 week after surgery and careful and close patient follow-up to optimize results. Most importantly, we advocate close coordination of sinonasal and rhinoplastic care in a two-team approach to maximize care.

Simultaneous functional endoscopic sinus surgery and esthetic rhinoplasty in orthognathic patients

PURPOSE

Patients treated for dentofacial deformities may be predisposed to aggravated sinonasal disease postoperatively, particularly if concurrent rhinoplasty is performed. The authors present their experience with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and functional endoscopic sinus surgery (FESS).

PATIENTS AND METHODS

Thirteen patients were treated with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and FESS from January 2002 to December 2005. An operative algorithm for patients with dentofacial deformities requiring rhinoplasty was developed. The surgical procedure was performed under general anesthesia with nasotracheal intubation and maxillary/mandibular osteotomies first. Nasotracheal intubation was then converted to orotracheal intubation and FESS was performed. The third step was correction of the esthetic deformities of the nose through an open approach.

RESULTS

In all cases, it was possible to successfully complete the combined operation. Median operation time was: 2 hours and 18 minutes for orthognathic bimaxillary surgery, 54 minutes for rhinoplastic surgery; and 23 minutes for FESS. All the patients had good esthetic and functional results and were free from symptoms consistent with previous rhinosinusitis.

CONCLUSION

The combination of orthognathic surgery, rhinoplasty, and FESS in selected cases is safe and effective.

Concurrent endoscopic sinus surgery and rhinoplasty

BACKGROUND

Concerns over increased surgical risk and associated complications have been reported regarding concurrent endoscopic sinus surgery (ESS) and rhinoplasty procedures. The aim of this study was to evaluate the overall safety of these concurrent procedures in our experience.

METHODS

A chart review was performed on 48 consecutive patients undergoing concurrent ESS and rhinoplasty between January 1998 and January 2005 with a mean follow-up of 12 months. The extent of surgical procedures, revisions required, and postoperative complications were documented.

RESULTS

Thirty-one (65%) women and 17 (35%) men ranging in age from 16 to 56 years with a mean age of 37 years were included in this study. Forty-five patients (93.7%) underwent a primary rhinoplasty procedure, whereas the other three (6.3%) underwent a revision rhinoplasty. Four patients required minor rhinoplasty revision procedures for a rhinoplasty revision rate of 4/48 or 8.3%. Complications noted in three separate cases included partial nasal obstruction, pain near osteotomy site, and localized infection for a complication rate of 3/48 or 6.3%.

CONCLUSION

In this study, rhinoplasty revisions did not appear to be related to the fact that ESS was performed at the same time as rhinoplasty. In addition, the only complication possibly attributed to a combined approach was a postoperative infection that developed in an insulin-dependent diabetic patient who underwent a rhinoplasty for functional reasons. Consequently, we recommend screening patients with poor wound healing factors in addition to those with acute exacerbations of chronic rhinosinusitis or severe chronic rhinosinusitis before performing concurrent ESS and rhinoplasty. In our experience, complications noted during concurrent ESS and rhinoplasty were minor, indicating the overall safe nature of this combined procedure when performed in appropriate patients.