Is Computed Tomography Imaging of Deviated Nasal Septum Justified for Obstruction Confirmation?

Third-party payers request objective confirmation of the nasal septum deviation (NSD) severity by computed tomography (CT) before authorizing financial support for septoplasty. Previous studies have provided contradictory results related to the link between obstruction severity and CT-measured angle of the NSD. The aim of this study was to investigate whether the diverse CT morphology of NSDs (including previously neglected types and shapes) could predict obstruction severity. The study included 225 patients with NSD. The CT morphology of the septum was analyzed using 5 different classifications of NSD that are commonly used in the clinical practice and research. The angle of NSD was also measured. Nasal obstruction was assessed by the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. A relationship between CT morphology and the angle of the NSD and NOSE scores was analyzed using appropriate regression models. Patients with NSDs located in the anterior part of the septum always have some degree of nasal obstruction, while those with posterior NSDs did not necessarily report obstruction symptoms no matter how complicated NSD they have. Regression analysis did not reveal any causal relationship between NOSE scores and CT morphology and the angle of NSD. The presence of spurs and whether they divide nasal passages have no statistically significant predictive effect on the obstruction severity. The CT morphology and the angle of the NSD could not predict severity of the nasal obstruction. Requesting CT examination just to objectively confirm nasal obstruction is not justified.

Refinements in Saddle Nose Reconstruction.

Saddle nose correction remains a challenging procedure for rhinoplasty surgeons due to both aesthetic and functional issues. The most common causes of saddle nose are nasal trauma and prior septal surgery, and a defective relationship between the caudal septum and the anterior septal spine is the principal postoperative pathology. The authors propose their own classification system for saddle nose with one new category and several approaches to deal with this condition in accordance with the level of severity. They strongly advocate major septal reconstruction for most cases of saddle nose, either by placing extended spreader grafts, caudal extension grafts, or a new extracorporeally made L strut. For extreme cases, integrated dorsal implant with columellar strut can successfully bypass the saddled nasal dorsum without dissecting the septal mucoperichondrial pocket and achieve adequate dorsal height. Further dorsal augmentation can be achieved by applying side/gap grafts or dorsal onlay grafts in different forms. In cases with retracted columella, a premaxillary plumping graft is another useful technique. Finally, in autoimmune-related saddling patients, the evidence indicates that their aesthetic problems can be managed safely with surgery as long as the disease is well under control.

[The morphological and clinical aspects of the curvature of the nasal septum]. / Morfologicheskie i klinicheskie aspekty iskrivleniia peregorodki nosa.

The curvature of the nasal septum (NS) is one of the most widespread deformations of the facial skeleton. The objective of the present study was to substantiate the principles of and develop the rationale for the surgical correction and conservative treatment of this condition based on the morphological features of various types of deflection of the nasal septum. We have undertaken the morphological analysis of the osseous and cartilaginous structures determining the type and the shape of the curvature of the nasal septum together with the clinical analysis of different morphological variants of the deflection of the nasal septum making use of the R. Mladina classification. Type I-IV vertical deflections are regarded as the acquired deformities whereas type II deviations can just as well be congenital malformations. Types V and VI deflections can be a consequence of the birth injury resulting in the displacement of the nasal structures and leading to the curvature of the nasal septum. The authors describe the defects in the anatomical structures adjoining the nasal cavity associated with various types of the deflection of the nasal septum that the surgeons should take into account when planning and performing septoplasty.

The Saddle Deformity: Camouflage and Reconstruction.

This article presents a comprehensive review of past and present modalities in the surgical management of saddle nose deformities. Various surgical techniques, including allograft materials, are systematically reviewed. The senior author's surgical experience and current management approach are highlighted.

Nasal Base Retraction: A Treatment Algorithm.

BACKGROUND: Nasal base retraction results from cephalic malposition of the alar base in the vertical plane, which causes disharmony of the alar base with the rest of the nose structures. Correcting nasal base retraction is very important for improved aesthetic outcomes; however, there is a limited body of literature about this deformity and its treatment. OBJECTIVES: Create a nasal base retraction treatment algorithm based on a severity classification system. METHODS: This is a retrospective case review study of 53 patients who underwent rhinoplasty with correction of alar base retraction by the senior author (S.T.). The minimum follow-up time was 6 months. Levator labii alaque nasi muscle dissection or alar base release with or without a rim graft on the effected side were performed based on the severity of the alar base retraction. Aesthetic results were assessed with objective grading of preoperative and postoperative patient photographs by two independent plastic surgeons. Functional improvement was assessed with patient self-evaluations of nasal patency. Also, a rhinoplasty outcomes evaluation (ROE) questionnaire was distributed to patients. RESULTS: Comparison of preoperative and postoperative photographs demonstrated that nasal base asymmetry was significantly improved in all cases, and 85% of the patients had complete symmetry. Nasal obstruction was also significantly reduced after surgery (P < 0.001). The majority of patients reported satisfaction (92.5%), with an ROE total score greater than or equal to 20. CONCLUSIONS: New techniques and a treatment algorithm for correcting nasal base retraction deformities that will help rhinoplasty surgeons obtain aesthetically and functionally pleasing outcomes for patients.

Evaluation of nasal mucociliary transport rate according to nasal septum deviation type.

BACKGROUND: Nasal septum deviation (NSD) may affect mucociliary activity (MCA) to varying degrees, depending upon the severity of the deviation. We used rhinoscintigraphy to determine the impact of the various NSD types on MCA. METHODS: A recent classification describing 6 different forms of NSD was used to standardize the study. Forty-eight subjects were enrolled. Eight patients for each form of NSD were accrued for further study. Rhinoscintigraphy was performed using technetium 99m macroaggregated albumin ((99m) Tc-MAA) before and 3 months after surgery. Nasal mucociliary transport rate (NMTR), the half-time of (99m) Tc-MAA activity, and clearance rate over a 20-minute period were compared between groups. RESULTS: Preoperative NMTR and clearance rates were significantly lower and half-time was significantly longer in types 4 and 6 than in the other groups. Although the postoperative NMTR and clearance rates increased compared with preoperative values in all groups, the increase was significant only in types 2, 4, and 6. The postoperative half-time increased significantly compared with the preoperative values in types 2, 4, and 6. The postoperative rhinoscintigraphy evaluation revealed no significant differences among groups in NMTR, half-time, or clearance rate. CONCLUSION: NSD types 4 and 6 had lower preoperative NMTR and clearance rates and a longer half-time compared with the other groups. However, the postoperative values of these parameters were not significantly different among groups. Our results indicate that NSD types 4 and 6 had the greatest impact on MCA, suggesting that these patients may receive the maximum benefit from septoplasty.

Classifying deformities of the columella base in rhinoplasty.

BACKGROUND: Although much has been published with regard to the columella assessed on the frontal and lateral views, a paucity of literature exists regarding the basal view of the columella. The objective of this study was to evaluate the spectrum of columella deformities and devise a working classification system based on underlying anatomy. METHODS: A retrospective study was performed of 100 consecutive patients who presented for primary rhinoplasty. The preoperative basal view photographs for each patient were reviewed to determine whether they possessed ideal columellar aesthetics. Patients who had deformity of their columella were further scrutinized to determine the most likely underlying cause of the subsequent abnormality. RESULTS: Of the 100 patient photographs assessed, only 16 (16 percent) were found to display ideal norms of the columella. The remaining 84 of 100 patients (84 percent) had some form of aesthetic abnormality and were further classified based on the most likely underlying cause. Type 1 deformities (caudal septum and/or spine) constituted 18 percent (18 of 100); type 2 (medial crura), 12 percent (12 of 100); type 3 (soft tissue), 6 percent (six of 100); and type 4 (combination), 48 percent (48 of 100). CONCLUSIONS: Deformities may be classified according to the underlying cause, with combined deformity being the most common. Use of the herein discussed classification scheme will allow surgeons to approach this region in a comprehensive manner. Furthermore, use of such a system allows for a more standardized approach for surgical treatment.

Surgical approach to nasal valves and the midvault in patients with a crooked nose.

Management of the crooked nose and valve obstruction is a challenge for even the most experienced rhinoplasty surgeon. Optimal treatment to restore a functional airway and improve cosmesis requires addressing the nasal valves. Several different techniques are available to guide the rhinoplasty surgeon to achieve the best outcome.

The crooked nasal tip.

Successful treatment of the crooked nasal tip includes proper analysis and assessment, employment of the proper techniques, reaching ideal tip dynamics, and close follow-up. Both the caudal septum and the nasal tip cartilages must be addressed. When executed properly, satisfaction should be high for both the patient and the surgeon.

Seven fundamental procedures for definitive correction of unilateral secondary cleft lip nasal deformity in soft tissue aspects.

PURPOSE: It is accepted that patients who undergo appropriate primary repair for cleft lip will have secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category. PATIENTS AND METHODS: Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients. RESULTS: Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes. CONCLUSIONS: These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes.

Management of the short nose deformity in revision rhinoplasty.

The short nose is a complex and frustrating problem that many rhinoplasty surgeons face in their practice. It can be seen in both the hereditary nasal deformity patient as well as in patients having undergone previous nasal surgery. In the revision rhinoplasty patient, the short nose can result from overresection of the nasal dorsum, a deficiency in the middle third causing a saddle nose and tip retraction, and from structural loss in the lobule. Several methods have been described regarding the treatment of this deformity. They range from simple tip grafting in the mildly affected patient to complete nasal reconstruction in the patient with severe structural loss and skin retraction. We will discuss the anatomy of the short nose and describe our techniques for addressing specific deficiencies.

Classification of the deviated nose and its treatment.

OBJECTIVE: To present a simplified classification of the deviated nose and the associated treatment outcome. DESIGN: Retrospective analysis. SETTING: Tertiary care rhinology clinic. PATIENTS: Seventy-five individuals (49 males and 26 females) who underwent rhinoplasty for a deviated nose with minimum follow-up of 36 months. MAIN OUTCOME MEASURES: Depending on the orientation of 2 horizontal subunits (the bony pyramid and the cartilaginous vault) with respect to the facial midline, the nasal deviations are classified into 5 types: I, a straight tilted bony pyramid with a straight tilted cartilaginous vault in the opposite direction; II, a straight tilted bony pyramid with a concavely or convexly bent cartilaginous vault; III, a straight bony pyramid with a tilted cartilaginous vault; IV, a straight bony pyramid with a bent cartilaginous vault, and V, a straight tilted bony pyramid and a tilted cartilaginous dorsum in the same direction. RESULTS: Deformities of types I through V occurred in 24 (32%), 19 (25%), 19 (25%), 7 (9%), and 6 (8%) patients, respectively, in whom 1, 3, 2, 1, and 1 unsuccessful outcomes were found. Four of the 8 failed cases had been approached endonasally. CONCLUSION: The proposed classification for the deviated nose could serve as a valuable adjunct in the treatment of these patients.

New and detailed classification of saddle nose deformities: step-by-step surgical approach using the current techniques for each group.

BACKGROUND: Currently, saddle nose deformity is one of the most challenging deformities in all of rhinoplasty surgery. Recent advances in aesthetic reconstructive surgical techniques warrant discussion of this subject. METHODS: A review of saddle nose cases from January 2003 to February 2007 showed that the existence of an important subgroup exists, designated as septal saddle nose deformity. The pathophysiology was weakening or loss of septal support, bone, or both, but not the classic dorsal overresection. A prospective study of 33 consecutive cases was completed, with emphasis on analysis, classification, and treatment. RESULTS: Prior attempts at classification have emphasized cause. The author's study indicated that the majority of cases had multiple causes, the most common being trauma followed by septorhinoplasty (immediately or later), as opposed to simple fracture reduction. In addition, 23 of 33 cases were true secondary saddle nose deformities. Classification was divided into types. Different methods of composite reconstruction were devised according to each case and grade, which allows construction of a deep structural foundation layer that then is superimposed with an aesthetic layer. CONCLUSIONS: Septal saddle nose still is an important entity that must be recognized and treated, especially when it is progressive. Composite reconstruction offers a unique solution to saddle nose deformity because it is a flexible method of restoring structural support and aesthetic contour.

A new classification of septal deviations.

STATEMENT OF PROBLEM: Existing nomenclatures of septal deviation deal with the deformation of the nasal septum exclusively and are rarely used in daily clinical work. The aim of this study was to develop a classification of septal deviations based upon the anatomical structures of the nasal septum and common clinical concepts. METHODS OF STUDY: We included patients undergoing septoplasty alone or in combination with rhinoplasty or functional endonasal sinus surgery by reason of septal deviation. Immediately after surgery, the surgeon recorded intraoperative findings of the nasal septum and the nasal turbinates in a data sheet and a standardized drawing for every patient. MAIN RESULTS: Data from 1088 patients were analyzed. Six types of septal deviations were identified. This new classification of septal deviations was developed with special regard to clinical anatomical findings. Leading as well as concomitant pathological findings were assigned to the six types of septal deviation. The frequencies of occurrence of hyperplasia of the inferior turbinate and concha bullosa of the middle turbinate were specified. PRINCIPAL CONCLUSION: The systematic assessment of relevant structures may help to develop improved surgical strategies. Furthermore, the systematic teaching of young surgeons to perform septal surgery may be facilitated.

[Long-term effects of cleft lip repair taking into account of life lot of operated patients]. / Ocena odleglych wyników leczenia wady rozszczepowej twarzy z uwzglednieniem losów zyciowych operowanych pacjentów.

AIM: The purpose of the study was the estimation of late aesthetic and functional results after the treatment of the primary or primary and secondary cleft palate. We also analysed the cleft impact upon the patients' social lives. MATERIAL AND METHODS: The research was conducted on 50 individuals in the ages of 17 to 54, including 29 patients with complete primary and secondary cleft palate and 21 patients with primary cleft palate only. The following parameters were evaluated in the patients: general appearance of the face and detailed states of the lip, nose and occlusion. The self-assessment of the examined individuals and the facial cleft impact upon their social lives was taken under consideration. RESULTS: The facial aesthetics was judged as positive in 80% of the cases and the correlation between the authors' assessment and self-assessment of the patients was similar. Patients with an unilateral cleft lip achieved better aesthetic and functional results of the lip. However, individuals with a bilateral cleft lip achieved the better nasal shape. Occlusion was incorrect in 64% of the examined patients. Almost all of them continue their secondary level education and university studies. Some of them work in the professions they have been trained in. 38% of them are married or have constant partners and 32% of them have children. CONCLUSION: The plan of multidisciplinary treatment of a cleft lip and palate allows to obtain positive late results. Early psychological and pedagogical care procedures towards patients and their families facilitate proper mutual social relations, improves their self-assessment and prevent social troubles.

Saddle nose deformity: A new classification and treatment.

Treatment of saddle noses challenges the surgeon to provide esthetic form and functional improvement despite the presence of a limited amount of tissue to work with. The previous emphasis on alloplastic materials was a testament not only to the poor results obtained with autogenous tissues but also the unwarranted promise of the "miracles of modern chemistry." Only in the last 5 years have multiple surgeons begun to achieve outstanding results using autogenous tissues. It is hoped that this article will encourage younger surgeons to build on this foundation and provide hope to a group of patients who deserve our best efforts. Saddle nose and cleft lip nose deformity warrant a commitment to surgical excellence.

A new classification system and an algorithm for the reconstruction of nasal defects.

A new, comprehensive system for scoring and classification of nasal defects is proposed in this article. The soft tissue coverage of the nose is in continuity with the cheeks, glabella and upper lip and the osteocartilaginous infrastructure is in continuity with the two nasofrontal buttresses, the frontal bar and the palate. Soft tissues and the skeletal framework are divided into sub-units and these anatomic features are schematized on a logo. The sub-units are graded on the logo, depending on their gravity in reconstructive strategies. Any given nasal defect is described by shading the involved sub-units on the logo and the sum of the points appended each sub-unit gives the total score of defect. The severity of the tissue loss is assessed according to a "Classification System" which is derived from this scoring system. Nasal defects are classified into one of four main Types corresponding to their scores. One hundred twenty seven patients who were operated on for various nasal pathologies have been reviewed and nasal defects are scored and classified according to the proposed system. Application of this system to the spectrum of cases encountered in a 6 years period shows that it is based on anatomic grounds, easy to document and efficient transmission of objective information becomes possible. It also offers a useful algorithm to approach the reconstruction of nasal defects.

[Use of septo-rhinoplasty in the treatment of traumatic deviated nose].

OBJECTIVE: To explore the new classification and marking method for traumatic deviated nose treated by septo-rhinoplasty. METHODS: Twenty-six selected cases of traumatic deviated nose were analysed. There were 5 C-type cases, 12 O-type cases and 9 S-type cases. Deviated parameters were measured before and after operation. All patients were treated by seven-step method. RESULTS: Clinical data in seventeen patients including C-type and O-type were complete. There was significant difference in changes of deviated parameters before and after operation( t = 6.9031, P = 0.0001). The cure rate was 58.8%, the effective rate was 88.2%. CONCLUSIONS: The new clinical classification and marking method for traumatic deviated nose are suitable for clinical study. Septo-rhinoplasty is effective for traumatic deviated nose.