Rhinoplasty from a rhinologist's perspective: need for recognition of associated sinonasal conditions

Quality of Life Improvement in Concurrent Septorhinoplasty and Endoscopic Sinus Surgery

OBJECTIVES

Septorhinoplasty (SRPL) and functional endoscopic sinus surgery (FESS) are two frequently performed surgeries to improve quality of life (QoL) in patients with nasal symptoms. It has been demonstrated as a safe combination regarding complication rates, but patient satisfaction in concurrent surgery has not been adequately studied yet.

METHODS

Patients undergoing sole FESS due to chronic rhinosinusitis (n = 57), sole SRPL (n = 148), and concurrent surgery (n = 62) were prospectively evaluated for their disease-specific QoL before and one year after surgery. Each procedure was performed by the same surgeon (OCB). For SRPL, the patient-reported outcome measures Rhinoplasty Outcomes Evaluation (ROE) and Functional Rhinoplasty Outcome Inventory (FROI-17) were utilized, and for chronic rhinosinusitis, the Sino-Nasal Outcome Test-22 (SNOT22).

RESULTS

All three groups showed significant improvement in the postoperative QoL measurements (all p < 0.01). The postoperative improvements were slightly smaller in the concurrent surgery group compared with the single surgery groups measured with ROE (combined: +55.2 ± 9.3, single: +58.8 ± 9.8, p = 0.02), FROI total score (combined: +47.6 ± 5.2, single: +49 ± 5.4; p = 0.08) and SNOT22 (combined: +33.1 ± 6.7, single +34.5 ± 7, p = 0.26).

CONCLUSIONS

SRPL, FESS, and combined surgery improve disease-specific QoL. When applicable, surgeons may offer the benefits of a combined procedure without compromising the QoL gain.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1239-1245, 2024.

Trans-Nasal Endoscopic Repair of CSF Rhinorrhea: An Institutional Experience

Introduction

Cerebrospinal Fluid (CSF) rhinorrhea results from breakdown in the integrity of structures separating the subarachnoid space and nasal cavity, namely subarachnoid space and dura mater, the bony skull base and periostea alongside the upper aerodigestive tract mucosa. Endoscopic repair is considered the treatment of choice for CSF rhinorrhea. Our aim of study was to analyze the etiopathogenesis and outcomes of treatment.

Material and Methods

A retrospective study review of patients treated with endoscopic repair of CSF rhinorrhea at tertiary care hospital in ENT Department Benazir Bhutto hospital Rawalpindi from august 2013 to September 2017 identified 25 patients. Majority of them were male. The defects were closed in three layers using fat, fascia lata and nasal mucosa along with fibrin sealant in majority of patients. Pre operatively subarachnoid drain was placed in all patients. Patients were followed up to 3 months.

Results

Forty-four patients underwent endoscopic repair of CSF rhinorrhea. The age group ranged from 16 to 55 years. Of the total of 44 patients 26 (59%) were males and 18(41%) females. The mean age of the patients in our study was 32.8 ± 9.7. Post trauma CSF leak was seen up to 52.3% of the patients. The most common site of leakage was identified Cribriform plate area. Our success rate of endoscopic repair was 88.6%. The most commonly observed complication was meningitis that was observed in 2 (4.5%) of the patients that too were managed conservatively.

Conclusion

Accurate localization of site of leakage appears to be essential for successful endoscopic repair of CSF rhinorrhea. In our study cribriform plate area was commonly observed area of CSF leak. In our study, the success rate was 88.6% and low complication rate 4.5%.

Evaluation of diagnostic accuracy of cone beam computed tomography and multi-detector computed tomography for detection of anatomical variations in rhinoplasty

BACKGROUND

Different imaging techniques, such as multi-detector computed tomography (MDCT) scan and cone beam computed tomography(CBCT), are used to check the structure of the nose before rhinoplasty. This study aimed to evaluate the accuracy of two imaging techniques, MDCT scan, and CBCT, in diagnosing structural Variations in rhinoplasty for the first time.

METHODS

This diagnostic accuracy study was conducted on 64 rhinoplasty candidates who complained of snoring and sleep apnea or had a positive result in the examination with Cottle's maneuver or modified Cottle technique between February 2021 and October 2022 at 15- Khordad Hospital affiliated to Beheshti University of Medical Sciences. Before rhinoplasty, patients were randomly assigned to one of the CT and CBCT techniques with an equal ratio. Scans were assessed for the presence of Nasal septum deviation (NSD), Mucocele, Concha bullosa, and nasal septal spur by two independent radiologists. The findings of the two methods were evaluated with the results during rhinoplasty as the gold standard.

RESULTS

NSD was the most common anatomical variation based on both imaging techniques. The accuracy of CBCT for diagnosing Nasal Septum Deviation and Mucocele was 80% and 75%, respectively. The sensitivity, specificity, and accuracy of CBCT in detecting Concha bullosa were 81.3% and 83.3%, respectively. The Kappa coefficient between CBCT and intraoperative findings for diagnosing NSD and Concha Bullosa was 0.76 and 0.73, respectively (p < 0.05).

CONCLUSION

CBCT can be considered a suitable method with high accuracy and quality to evaluate the anatomical variations before rhinoplasty.

In-office Endonasal Minor Revision Rhinoplasty

The revision rhinoplasty presents many unique challenges to the facial plastic surgeon. While many cases will require a full revision in the operating room, there are several isolated deformities which may be repaired in the office via an endonasal approach. This provides many benefits to the patient and surgeon including decreased cost, shorter recovery time, avoidance of general anesthesia, and less discomfort. It is critical to identify defects appropriate for endonasal repair, establish clear expectations with the patient, and work within one's skill set and level of experience. The surgeon who can comfortably navigate both open and endonasal techniques can offer their patients a comprehensive set of solutions for revision rhinoplasty. In this article we outline the defects amenable to this type of repair as well as technical considerations for each defect addressed. We hope it serves as a useful framework for the range of deformities the rhinoplasty surgeon may take on for in-office repair.

Cone-Beam Computed Tomography: A User-Friendly, Practical Roadmap to the Planning and Execution of Every Rhinoplasty-A 5-Year Review

BACKGROUND

Cone-beam computed tomography has recently rapidly developed worldwide as a versatile and convenient alternative to traditional computed tomography for imaging of the maxillofacial region. However, most surgeons performing rhinoplasty are surprisingly unfamiliar with it, in both the plastic surgery and ear, nose, and throat communities.

METHODS

The broad clinical experience of a single center over the past 5 years is reviewed. The many applications of cone-beam computed tomography to primary and secondary rhinoplasty are analyzed regarding septum, turbinates, nasal bones, skin thickness, and other issues. The importance of a paradigm shift from a two-dimensional to a three-dimensional approach in image reconstruction is demonstrated, together with the value of surface contour enhancement.

RESULTS

Cone-beam computed tomography has a multitude of practical applications highly relevant to rhinoplasty. The surface image will strengthen aesthetic analysis, and the detailed preview of bony and functional anatomy will facilitate surgical planning. Cone-beam computed tomography serves as a roadmap to plan and execute rhinoplasties more predictably and efficiently. The availability of spatial views and accurate detail, together with the possibility of easy, accurate measuring, offers a plenitude of potential applications.

CONCLUSIONS

Cone-beam computed tomography is a user-friendly, quick technique with abundant advantages in planning any rhinoplasty. It causes the patient no inconvenience and has very few, if any, drawbacks, with these being limited to radiation exposure and limited cost.

Assessing the Clinical Value of Performing CT Scan before Rhinoplasty Surgery

Introduction

The endonasal mucosal or anatomic pathologies could lead to poor functional results and dissatisfaction after rhinoplasty. Although computed tomography (CT) scan has become an integral part of the diagnostic paradigm for patients with pathologies of the paranasal sinuses, the use of CT scan for preoperative evaluation of patients seeking rhinoplasty is up for debate. Our aim in this study was to compare the efficacy of CT scan in diagnosing nasal pathologies with other evaluating tools in patients undergoing rhinoplasty.

Design

In this randomized controlled trial study, 74 consecutive patients seeking cosmetic rhinoplasty referred to otorhinolaryngology clinic were randomly assigned into three groups based on the perioperative evaluation method: the CT group, the nasal endoscopy group, and the control group (anterior rhinoscopy only). Surgical planning was made according to perioperative findings, and the identified endonasal pathologies were corrected during the surgery. The functional and aesthetic outcomes of the rhinoplasty were assessed by Nasal Obstruction Symptom Evaluation (NOSE), Rhinoplasty Outcome Evaluation (ROE), and the Visual Analogue Scale (VAS) tools before surgery and at 12-month follow-up.

Results

All outcome measures improved significantly in either group toward one year after rhinoplasty (all with p value <0.05). Subjects in the CT group demonstrated greater improvement in the NOSE, VAS, and ROE compared to other two groups (NOSE: p value = 0.17; VAS: p value = 0.024; ROE: p value = 0.042).

Conclusions

According to our study, perioperative CT is associated with greater patients' satisfaction and quality of life after rhinoplasty compared to either nasal endoscopy or anterior rhinoscopy. A preoperative CT scan may improve the outcomes of rhinoplasty.

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.

Association of Mental Health Status With Perception of Nasal Function

Importance

Mental health issues are thought to be overrepresented among patients undergoing rhinoplasty and may be associated with patient presentation prior to surgery.

Objective

To assess the association of poor mental health with perception of nasal function.

Design, Setting, and Participants

A cross-sectional study of patients presenting for airway assessment was performed from December 1, 2011, to October 31, 2015, at 2 tertiary rhinoplasty centers in Sydney, Australia. Mental health was independently defined preoperatively by the Mental Component Summary of the 36-item Short Form Health Survey version 2 (a score of <40 indicated poor mental well-being), the Rosenberg Self-Esteem Scale (a score of <15 indicated low self-esteem), and the Dysmorphic Concerns Questionnaire (a score of >11 indicated above-average dysmorphic concerns).

Main Outcomes and Measures

Nasal function was assessed with patient-reported outcome measures, including the Nasal Obstruction Symptom Evaluation Scale, the 22-item Sinonasal Outcome Test, a visual analog scale to rate ease of breathing on the left and right sides, and Likert scales to assess overall function and nasal obstruction. Nasal airflow was assessed by nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area.

Results

Among 495 patients in the study (302 women and 193 men; mean [SD] age, 36.5 [13.6] years), compared with patients with good mental health, those with poor mental health had poorer scores in all patient-reported outcome measures, including the visual analog scale for the left side (mean [SD], 51 [25] vs 42 [25]; P = .001), visual analog scale for the right side (mean [SD], 54 [24] vs 45 [26]; P < .001), Nasal Obstruction Symptom Evaluation Scale (mean [SD], 2.64 [0.95] vs 1.96 [1.04]; P < .001), 22-item Sinonasal Outcome Test (mean [SD], 2.14 [0.84] vs 1.33 [0.83]; P < .001), nasal obstruction (58 of 145 [40.2%] vs 83 of 350 [23.7%] with severe or worse obstruction; P < .001), and nasal function (72 of 145 [49.7%] vs 111 of 350 [31.8%] with poor or worse function; P < .001). Subclinical differences in nasal peak inspiratory flow could be demonstrated, but all other nasal airflow measures were similar. Low self-esteem produced a similar pattern, but dysmorphia did not.

Conclusions and Relevance

Poor mental health status is associated with a poorer self-perception of nasal function compared with those who are mentally healthy with clinically similar nasal airflow. Clinicians should be aware that patients with poor mental health reporting obstructed airflow may in part be representing an extension of their negative emotions rather than true obstruction and may require further assessment prior to surgery.

Level of Evidence

NA.

Tension-relaxing method-A simplified revision of the endoscopic septoplasty technique: For both aesthetic appearance and functionality

OBJECTIVE

This article describes a simplified endonasal approach compared with traditional techniques for the correction of crooked noses by using endoscopic tension-relaxing septoplasty in the absence of nasal splints, with attempts to improve both the aesthetic appearance and functionality.

STUDY DESIGN

A retrospective study was conducted at our institution with all 26 patients who underwent tension-relaxing rhinoseptoplasty by endoscope between November 2008 and January 2013.

METHODS

Patients who were concerned about their aesthetic appearance and nasal obstruction were subjected to anterior rhinoscopy, endoscopic examination of the nasal cavity, and computed tomography for the evaluation of correlations among deformity of the nasal structures and nasal airway. The tension-relaxing method was used in the endoscopic rhinoseptoplasty by an endonasal approach. We introduced this technique in the surgery for patients with a C- or an I-shaped crooked nose. Subjective (visual analog scale) and objective (quantitative electronic meter measurement) assessments were used to evaluate aesthetic appearance. Validated Nasal Obstruction Symptom Evaluation scale and active anterior rhinomanometry were used to assess nasal obstruction.

RESULTS

All the patients indicated cosmetic satisfaction and reduced nasal obstruction. In cases with I-shaped and C-shaped crooked nose deformities, pre- and postoperative angle values (mean ± standard deviation) were 13.35 ± 3.36° versus 1.85 ± 1.66° (n = 15) and 153.69 ± 6.48° versus 176.64 ± 2.32° (n = 11), respectively. Postoperative correction rates were statistically significant (p < 0.001) in both groups. Results from active anterior rhinomanometry indicated significant improvement in objective nasal obstruction from a mean baseline value of 0.56 ± 0.07 Pa/cm(3)/s (range, 0.43- 0.69 Pa/cm(3)/s), to a 12-month value of 0.26 ± 0.02 Pa/cm(3)/s (range, 0.23-0.29 Pa/cm(3)/s) (p < 0.001). The mean rhinoseptoplasty duration time was 19.00 ± 3.53 minutes. The nose deformities were significantly improved, with no recurrences of septal deviation or crooked nose, nor complications of septal perforation and nasal infection 12 months after the operation.

CONCLUSION

This simple technique is feasible and minimally invasive, and may be particularly beneficial to patients with a deviated septum who seek to improve both their aesthetic appearance and nasal functionality. However, this method is not appropriate for those with a crooked nose caused by nasal bone deformity, lateral cartilages, and severe septal deformity.

Anatomical Variations of Ostiomeatal Complex in CBCT of Patients Seeking Rhinoplasty

STATEMENT OF THE PROBLEM

Anatomic variation can potentially impact the surgical safety.

PURPOSE

The purpose of this cross-sectional study was to assess the prevalence of ostiomeatal complex variations based on cone beam computed tomography (CBCT) images of the patients seeking rhinoplasty.

MATERIALS AND METHOD

In this cross-sectional study, CBCT images of 281 patients including 153 female and 128 male with Mean±SD age of 26.97±7.38 were retrieved and analyzed for presence of variations of ostiomeatal complex and mucosal thickening. All CBCT images were acquired by NewTom VGi scanner with 15×15 field of view, as a part of preoperative recording of patients seeking rhinoplasty in an otolaryngology clinic. Chi- square test and Odds ratio were used for statistical analysis of the obtained data and p< 0.05 was considered to be statistically significant.

RESULTS

Agger nasi cells which were seen in 93.2% of the cases were the most common anatomic variation. It was followed by Haller cells (68%), concha bullosa (67.3%), uncinate process variations (54.8%), nasal sepal deviation (49.5%) and paradoxical curvature of middle turbinate (10%). Mucosal thickening were detected in 60.7% of the studied cases.

CONCLUSION

Ostiomeatal complex variations and mucosal thickening are considerably prevalent among the patients seeking rhinoplasty. This study also revealed that CBCT evaluation of paranasal sinuses has comparable result in delineation of the sinonasal anatomy.

Evaluation of polyvinylidene fluoride nasal sensor to assess deviated nasal septum in comparision with peak nasal inspiratory flow measurements

BACKGROUND

Deviated nasal septum (DNS) is one of the major causes of nasal obstruction. Polyvinylidene fluoride (PVDF) nasal sensor is the new technique developed to assess the nasal obstruction caused by DNS. This study evaluates the PVDF nasal sensor measurements in comparison with PEAK nasal inspiratory flow (PNIF) measurements and visual analog scale (VAS) of nasal obstruction.

METHODS

Because of piezoelectric property, two PVDF nasal sensors provide output voltage signals corresponding to the right and left nostril when they are subjected to nasal airflow. The peak-to-peak amplitude of the voltage signal corresponding to nasal airflow was analyzed to assess the nasal obstruction. PVDF nasal sensor and PNIF were performed on 30 healthy subjects and 30 DNS patients. Receiver operating characteristic was used to analyze the DNS of these two methods.

RESULTS

Measurements of PVDF nasal sensor strongly correlated with findings of PNIF (r = 0.67; p < 0.01) in DNS patients. A significant difference (p < 0.001) was observed between PVDF nasal sensor measurements and PNIF measurements of the DNS and the control group. A cutoff between normal and pathological of 0.51 Vp-p for PVDF nasal sensor and 120 L/min for PNIF was calculated. No significant difference in terms of sensitivity of PVDF nasal sensor and PNIF (89.7% versus 82.6%) and specificity (80.5% versus 78.8%) was calculated.

CONCLUSION

The result shows that PVDF measurements closely agree with PNIF findings. Developed PVDF nasal sensor is an objective method that is simple, inexpensive, fast, and portable for determining DNS in clinical practice.

Upper lateral strut graft: a technique to improve the internal nasal valve

BACKGROUND

Internal nasal valve (INV) collapse can contribute significantly to nasal obstruction and may be caused by upper lateral cartilage (ULC) collapse medially or laterally. Surgical techniques addressing INV collapse have focused more on treating the narrowed INV angle, with less consideration of the lateral INV area. This article describes a technique to improve INV patency both medially and laterally. This study analyzes the changes in minimal cross-sectional area (MCA) at the INV after graft placement and determines whether these changes are significantly different for normal versus narrow INVs.

METHODS

Noses of six fixed cadavers were dissected by open rhinoplasty to release the ULCs from the septum. Upper lateral strut grafts were placed through subperichondrial pockets along the ULC undersurfaces and out over the piriform apertures into subperiosteal pockets. Grafts were secured to the dorsal septum. Acoustic rhinometry and nasal endoscopy were used to classify INVs before graft placement as narrow or normal and to assess changes at the INV after graft placement.

RESULTS

Mean pregraft MCA was 0.58 cm(2). Mean MCA percent increase after graft placement was 22%. By INV type, percent increases were 51% for narrow INVs and 1% for normal INVs. Mean increases in MCA after graft placement were statistically significant for the entire group and for narrow INVs, with increases of 0.10 cm(2) (p = 0.03) and 0.22 cm(2) (p = 0.004), respectively.

CONCLUSION

The upper lateral strut graft improved patency of cadaveric INVs, with statistically significant increases in the MCA most notable when placed for narrow INVs.