The nose functional surgery includes three different surgical techniques depending on the defect that you want to correct: deviation of the nasal septum, hypertrophy of the turbinates or nasal polyps. Before proceeding with a functional nose surgery, it is necessary to undergo an accurate specialist examination using a rhinoscope and optical fibers, so that the plastic surgeon can evaluate, in addition to the aesthetics of the nose, the possible presence of possible anatomical defects that can determine changes in respiratory function. Functional nose surgery can be performed alone or in combination with rhinoplasty and prophyloplasty. For all these types of surgery it is advisable to wait for the end of the development of bone and cartilage structures which generally takes place around 15-16 years for women and 16-17 years for men.
INTERVENTION FOR THE DEVIATED NASAL SEPTUM – SEPTOPLASTICS
Septoplasty is a functional surgery of the nose aimed at solving respiratory problems by repositioning and aligning the deviated septum. The deviations of the nasal septum are extremely varied in shape and direction: they can be C, S or V lying down.
In nature there is no perfectly straight nasal septum and each septum has a small or large deviation. The deviation is often accompanied on the side of its concavity by a hypertrophy of the inferior or middle turbinate.
The deviation of the nasal septum can also be present with an aesthetically straight nose, but more often it is associated with a deviation of the nasal pyramid (nasal scoliosis). The deviations can be cartilaginous or osteo-cartilaginous.
The cartilaginous deviations affecting the quadrangular cartilage (or the nasal septum cartilage) and may consist of a:
1) dislocation of the lower edge of the cartilage with narrowing of one of the nostrils;
2) chondro-vomeral dislocation;
3) chondro-ethmoid dislocation;
4) superior deviation of the quadrangular cartilage with nasal scoliosis.
The osteo-cartilaginous deviations affecting the ploughshare and the lamina perpendicular ethmoid. They are more posterior and mostly angular deviations.
The deviation of the nasal septum is hardly present from birth, it usually appears with the passing of the years and is accentuated when development is complete (16 or 17 years). This defect is favored by a prolonged bad nasal breathing (adenoid hypertrophy) which determines the formation of an “ogival” palate, which due to its conformation prevents the normal vertical development of the nasal septum with consequent deviation to C, S or V.
Other times the deviation is acquired, mainly due to severe trauma or as a consequence of previous surgical interventions.
The symptomatology is mainly of nasal obstruction, sometimes on one side only, with hypertrophy of the turbinates (especially in case of vasomotor rhinitis), but also of mucous or mucus-purulent phlegm for pharyngo-laryngeal or broncho-pulmonary catarrhal infections. Complications like tubaritis or catarrhal or purulent otitis are also not uncommon, as are the appearance of acute and chronic sinusitis. Also frequent are headaches and nosebleeds.
Diagnosis is performed with anterior rhinoscopy or, in the case of posterior bone deviations, with a simple X-ray of the skull.
The therapy is surgical: the intervention lasts about 20 minutes, is performed under general anesthesia and in a day hospital regime, and consists in repositioning and removing the deviations of the nasal septum using traditional or endoscopic techniques.
SURGICAL INTERVENTION OF THE TURBINATES
The turbinates , four on each side, are formations detected and elongated from front to back , which we can schematically consider horizontal and parallel to the floor of the nose. They consist partly of bone and partly of mucous tissue and their main function is to humidify and heat the air before it reaches the nasopharynx.
In the space below each turbinate there is a meatus that takes its name from the turbinate above it. The inferior meatus, placed between the inferior turbinate and the floor of the nasal fossa, is the outlet of the nasolacrimal canal. The closure of this orifice for a congestion of the mucous membranes, for example for a cold or for a hypertrophy of the inferior turbinate, causes a profuse tearing (epiphora).
The middle meatus is located below the middle turbinate and above the inferior turbinate. It is the most important part of the nasal passages because in this region the paranasal sinuses (maxillary and frontal) and ethmoidal cells blossom.
The superior meatus is located above the middle turbinate in which the posterior ethmoidal cells and the spheroidal sinus bloom.
The turbinates are made up of a bone component, which does not change over time, and a mucous part which, due to acute, chronic inflammation, allergic rhinitis, menstruation, pregnancy, emotional stimuli, etc. … can enlarge and determine the so-called “hypertrophy of the turbinates” .
To evaluate the functionality of the turbinates, in addition to a careful visit by the specialist, an evaluation through a very simple examination called rhinomanometry may also be necessary. This examination allows to evaluate the quantity and resistance to the passage of air through the nostril.
From a symptomatological point of view, hypertrophy of the turbinates determines: nasal obstruction (which can sometimes be from a nostril, sometimes from both nasal passages), respiratory difficulty, epiphora for closing the lower meatus, hyposmia ( decreased perception of odors), headache due to clogging of the paranasal sinuses due to obstruction of the middle and upper meatus, rhonchopathy (“snoring”), pharyngitis and recurrent otitis.
The surgical technique for reducing turbinate hypertrophy is much less invasive than a few years ago. The traditional turbinectomy (complete removal of the turbinates, positioning of swabs, etc.) or partial submucosal decongestion is increasingly used. Often, in fact, the operation is performed under local anesthesia and in the day hospital regime, and involves the use of new methods such as the Co2 laser, Neodymium-Yag laser or radiofrequency electrosurgical unit or the simpler “debrider”.
SURGICAL INTERVENTION OF NASAL POLYPES
Nasal polyps are pedunculate formations, often multiple, sometimes solitary (anthrocoanal polyp). The cause of the onset of nasal polyposis is not entirely clear and is probably multifactorial: it has in fact been shown that some nasal polyps have an immune onset due to the presence of type E immunoglobulins (IgE); others, however, are determined by chronic inflammatory processes.
The polyp is a rounded, pedunculated, yellow or pinkish-pink formation, with a gelatinous or hard elastic consistency depending on the percentage of collagen fibers present. The polyps can be so large that they occupy an entire nasal fossa and descend through the coana into the nasopharynx, and are generally multiple. In some cases, the growth of the pulpy masses can lead to growth and deformation of the external nose (Woakes syndrome).
The presence of nasal polyposis is also frequent in the course of mucoviscidosis, a disease that affects children and which is mainly characterized by alteration of all mucous secretions, by Kartagener syndrome, sinuous-bronchial syndrome and Young syndrome.
The subjective symptomatology of nasal polyposis is generally represented by more or less complete nasal obstruction, by hyposmia and anosmia, headache, by otitis and respiratory difficulty due to descent of catarrhs from the nose into the pharynx.
Diagnosis is performed by anterior and posterior rhinoscopy which highlights the presence of pulpy masses through the nostrils or in the nasopharynx. An X-ray of the skull may be required to detect the presence of polyps in the paranasal sinuses.
In mild forms, in which there are only a few small polyps, the therapy is medical and is aimed at treating any allergic causes (antihistamines, cortisone, etc.).
Therapy is surgical in the majority of cases because the patient usually turns to the specialist when the nasal obstruction is very advanced.
The surgery lasts about an hour, is performed under general anesthesia, in hospitalization or day hospital, and consists of the removal of the nasal polyps and the emptying of the ethmoid cells and the sick paranasal sinuses.
