Nose and paranasal sinuses
Straightening of the nasal septum (septoplasty)
The aim of septoplasty is to reduce nasal obstruction, improve breathing during sleep, eliminate snoring and restore proper functioning of the ciliary apparatus which purpose is to clean and warm inhaled air..
Septoplasty involves intranasal cutting of the mucosa that allows to correct deformed part of the cartilage and bone of the nasal septum without leaving scars. The procedure is very precise due to use of endoscopic techniques. It is performed under general or local anaesthesia and lasts approx. 1 hour. General anaesthesia provides comfort to the patient, enables the appropriate control of the arterial blood pressure, thus reducing bleeding during surgery
Septum divides the interior of the nose. It is formed from bone and cartilage. Nasal septum should be located in the middle line of the nose. When its deviation reduces patency of the nasal cavity, it hinders the airflow. The most common cause of deviated nasal septum is an injury. This may include injury to the nose which occurred recently or in a distant past, e.g. in the childhood, or even a perinatal injury as the deviation may result in discomfort long after trauma regardless of the fact that lesions are often more exacerbate in time and in children deviation of the septum may increase with growth. The most common problem reported by patients with deviated septum includes unilateral or bilateral limitation of nasal patency. Obstruction in such cases often exacerbates during the night and may result in sleep disturbances. Another symptom of deviated nasal septum may include recurring infections of paranasal sinuses.
Indications to surgery in the case of deviated septum include: difficulties in breathing through the nose, recurring diseases of paranasal sinuses or tear ducts, recurrent nose bleeds, insufficient nasal patency affecting speech, exacerbated allergic mucosal changes, cosmetic reasons in the cases of visible deviation of nasal cartilage. The aim of septoplasty is to straighten (correct) the septum. Septoplasty consists in minimal resection of cartilage and bone (e.g. only removal of ridges and spurs) as well as in careful setting of mobilised cartilage and bone skeleton of the septum in the middle line of the body. The aim of the surgery is to improve breathing through the nose, restore symmetry of the intranasal symmetry without changing its appearance, removal of nasal obstruction which reduces snoring. Usually, this procedure is performed under general anaesthesia. Surgery lasts for approx. 1 hour. It is usually performed in a one-day mode. After the surgery, swelling of the mucosa may occur and may last for 10-14 days. For over 4 days, secretion with blood may be present. Nose may be swollen and reddened. Travelling by air and exercising should be avoided for 10 days after the surgery. There are several possible complications which include: risk of nose bleeds requiring return to hospital, nose infection requiring treatment with antibiotics, sometimes perforations in the nasal septum may occur after its correction
Correction of external nose deformations (rhinoplasty)
Two types of nose surgery techniques can be distinguished:
Non-delivery approach - it is recommended in the following cases:
Delivery approachThis method is indicated in the cases which aim is to change the shape of the nose in the greater extent than just simple and slight decrease in its volume. Such approach is indicated in the following cases:
- Internal rhinoplasty approach also referred to as closed rhinoplasty - which involves incision made inside the nose, thus making the scars invisible. Internal access may be conducted with the application of non-delivery or delivery approach.< >slight decrease in the volume of the lateral crus of greater alar cartilage;slight cranial rotation of the tip of the nose.asymmetry of the tip of the nose;
- split nose tip;
- excessive rotation of the tip towards the cranium;
- decrease of tip projection. Such approach allows to model greater alar cartilages to the region of domes and area between them under direct visual control.
- External rhinoplasty approach, also referred to as open rhinoplasty - postoperative scars may be visible because surgeon makes the incision perpendicularly to the nasal septum. Access to deeper anatomic structures of the nose is obtained by combining transverse incision on the columella with bilateral incisions on the nostrils. Incision on the columella is made midway between upper edge of the nostrils and point at the base of the nose. Using this approach a surgeon modifies anatomic structures inside the nose. This method has numerous advantages but also disadvantages. The advantage includes better access to the anatomic structures of the nose which are the cause of external deformation of the nose. Techniques used during external rhinoplasty which ensures maximal exposition allow for more precise suturing.
Incision in the columella
This approach is frequently used in the following deformations:
- asymmetry of the tip of the nose,
- deviated nose, saddle nose,
- improper positioning of the top of the nose,
- deformations in patients with thick skin of the nose.
The choice of this methods is supported by the need to supplement the tissue (augmentation). Long-lasting swelling and marks after surgical incisions are the disadvantage.
Secondary rhinoplasty- this is the second surgery of the nose- reoperation. In such situation, tissues are deformed and altered, improperly supplied with blood as a result of one or several plastic surgeries.
Nasal hump surgery:
At the beginning of the procedure, surgeon moves the skin from the skeleton on the bridge of the nose and a mucous membrane from the inside. Therefore, she or he performed one of possible incisions, e.g. incision under alar cartilage or transverse to the nasal septum. Nasal hump is removed with use of special tools. In some cases, cut tissue is used to remodel the nose. Implant must be secured against movement. Sometimes to immobilise the implant, it is enough to put on an external plaster dressing.
Nasal hump modelling
Consultation with a physician:
During the first consultation, details of the correction and type of anaesthesia are determined, photographic and computer simulation of postoperative effect is made, duration of the patient’s stay in the clinic is estimated (usually patient is discharged on the same day). Full and precise assessment of external and internal nose based on palpation and rhinoscopy allows to specify the nature of the problem and selection of surgical technique. During the first appointment, surgeon conducts detailed conversation with a patient during which surgical treatment possibilities are presented. Ideas about the surgery, its limitations, risks or postsurgical complications are discussed. Patient has the right to ask physician questions so that he or she can obtain all necessary information and be fully aware of the future procedure. Consultation with anaesthesiologist is performed as well.
Examinations performed before surgery:
The following laboratory tests must be performed: complete blood count, bleeding time and clotting time, blood type and ECG test. It is possible that computed tomography of the nose and paranasal sinuses will be recommended. There are no clear contraindications preventing from performing rhinoplasty.
Relative contraindications include: diabetes, anaemia, untreated hypertension, inflammation of paranasal sinuses and face.
The course of the surgery:
The surgery usually lasts 1-3 hours. However, more complicated procedures may last much longer. Typical surgery consists in the first place in separating the skin from the nose, partial removal and possible modelling of the alar cartilages and nose tip and, if necessary, removal of the nose hump and narrowing the bone part of the nose.
The procedure may be performed under general anaesthesia or sometimes under local anaesthesia depending on the patient's needs and preferences.
Patient remains in the clinic for several hours after the procedure. After the surgery, nose is stabilised with thermoplastic dressing (modern plaster cast) from its external part for 7 days. Delicate dressings are placed inside the nose. Recovery time lasts for approx. 2 weeks. The course of perioperative process is usually painless. "Boxing” circles under the eyes may be present but they usually subside after 7-10 days. Due to the healing process and swelling, complete effects of the procedure can be seen after several weeks. Social activity is allowed after 7-14 days. Postoperative control takes place after 3, 6 and 12 months.
Severe complications after surgery of the nose do not happen very often. The less severe complications include: change of the nose colour, cracking of tiny blood vessels, delayed healing of postoperative wound, headaches.
Correction of hypertrophy and different anatomical structure of nasal turbinates.
Lower nasal turbinate surgery (conchoplasty) is mainly based on reduction of the turbinate mucosa volume. Currently, one of the commonly acknowledged treatment method of turbinate hypertrophy is conchoplasty performed radiosurgically. It consists in entering under the turbinate mucosa special electrodes and stimulation of soft tissues with a waves of radio frequency. As a consequence, scar tissue (connective tissue) is formed inside nasal turbinates tissue (submucosally) which leads to shrinking of turbinates and reducing their volume. Due to application of radiosurgery, this a minimally invasive procedure. The leading surgical technique used by us in correction of nasal turbinates is a RFITT bipolar thermoablation using the Celon apparatus. The procedure consists in low-temperature (approximately 80oC) coagulation with high-frequency waves of precisely determined range. The surgery is usually performed under local anaesthesia. The entire procedure takes 10 to 20 minutes and does not require hospitalization.
Endoscopic surgeries of paranasal sinuses
FESS - Functional endoscopic sinus surgery This method’s aim is to reduce symptoms of paranasal sinus inflammation and/or nasal polyps. It is a minimal surgical intervention individually adjusted to the needs of each patient. It is recommended for such patients, who treatment with intranasal medicines or antibiotic therapy do not result in any improvement. FESS is performed through the nostrils under general anaesthesia. It does not leave scarring on the facial skin. During the surgery, thin plates of the bone and inflamed mucous membrane are removed. Surgeon uses special tools adapted to the procedure so that minimal scarring would occur during healing of postoperative scar in the nose which in turn enables much faster recovery. After the procedure, nose patency may be limited for maximally 2 weeks. Patient may feel slight discomfort or feel tired for some time.
FESS procedures are currently the main and modern methods to treat chronic sinusitis. A patient is qualified for surgical treatment on the basis of laryngological consultation at the appointment during which physician performs endoscopic examination of the nose. Computed tomography of the nose and paranasal sinuses is performed before the procedure which assesses the lesions in the paranasal sinuses. Procedure is performed under local anaesthesia with use of microsurgery of paranasal surgery accompanied by visualisation. This assumption which lies behind this method is to remove lesions in the sinus ostia which cause disorders related to ventilation and drainage of paranasal sinuses. Functional endoscopic microsurgery of chronic inflammation of paranasal sinuses is a surgical technique of choice and consists in minimal surgical intervention in the initial phases of the inflammatory process. It is conducted intranasally without the necessity to cut the facial skin.
The procedure is performed under the endoscopic control which allows to remove only those tissues which are covered by the disease process while maintaining uninflamed anatomic structures intact. One of the FESS’s advantages is a short hospitalisation time of the patient. The aim of the procedure is to restore proper ventilation of paranasal sinuses. Long-term persistence of disturbed ventilation is a main reason of changes in the mucous membrane and accumulation of secretion inside the lumen of the sinuses which form a basis for inflammatory process. Removal of mucous membrane of the inflamed tissue has a beneficial effects of the healing process and effective elimination of causes of sinusitis. FESS is conducted with the use of special microsurgical tools entered intranasally which allows to avoid cutting the skin on the face.