bailey words

7/25/2019 Bailey Words

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Editors: Bailey, Byron J.; Johnson, Jonas T.; Newlands, Shawn D.Title: Head & Neck Surgery !tolaryngology, "th Edition#o$yright % '(() *i$$incott +illia s & +ilkins- Ta le o/ #ontents - 0olu e !ne - 11 2hinology and 3llergy - '4 Surgical 5anage ent o/ Se$tal De/or ity, Tur inate Hy$ertro$hy, Nasal 0al6e #olla$se, and #hoanal 3tresia'4Surgical 5anage ent o/ Se$tal De/or ity, Tur inate Hy$ertro$hy, Nasal 0al6e #olla$se, and#hoanal 3tresia5ichael 7ried an2a akrishnan 0idyasagar Nasal o struction is a co on $resenting sy $to in the $ractice o/ otolaryngology. The ost

co on diagnoses o/ nasal o struction are $resented in Ta le '4.8. So eti es ulti$lecontri uting $rocesses cause nasal o struction. Strategies /or the anage ent o/ nasalo struction are ased $ri arily on history, $hysical e9a ination, and results o/ la oratory tests,where a$$lica le. 1t should also e understood that so e o/ the o 6ious /indings, such as se$talde6iation, ay not e the only contri uting cause /or the nasal o struction, and ay ust e anincidental /inding. #are should always e taken to analy e the $atient as a whole, rather than thenose as a se$arate organ. hy$o$nea syndro e ?!S3HS@, and S A gren syndro eC can $resentwith nasal o struction as a $art o/ their edical disease with or without any locali ed nasal/inding. 3 thorough assess ent o/ all $otential causes o/ nasal o struction is essential e/orede/initi6e treat ent o/ a single anato ic o struction.Se6eral /actors ay in/luence the sensation o/ co /orta le nasal reathing, including the a ountand ty$e o/ nasal air/low, the sensation registered /ro the intranasal skin or ucosa y the $assing air, and the condition o/ the nasal ucosa. 5any $hysiologic and $athologic conditionsa//ect the a ount o/ air/low through the nose. The nasal $athologic conditions include ucosalhy$eracti6ity, se$tal or other structural de/or ities, $oly$s, tu ors, sinus in/ection, granulations,and synechiae. 3ny one o/ these or any o/ these together ay e the /actors that li it air/lowin a $erson who co $lains o/ nasal o struction.History


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The /irst ste$ in assessing any sy $to is to o tain a thorough history. The clinician should $ay $articular attention to the ti e o/ onset, se6erity and duration o/ sy $to s, and recourse the $atient has taken to alle6iate sy $to s. The history should deter ine i/ the o struction isunilateral, ilateral, or alternating; the duration o/ the o struction ?recurrent or chronic@aggra6ating /actors;


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hy$ertro$hy outh reathing, snoring, crowding o/ teeth

9 ray naso$haryngeal lateral 6iew

!S3HS Thick $alate, hy$ertro$hic tonsils hy$o$nea syndro e; 23ST,radioallergosor ent test5ost $atients with nasal o struction descri e generali ed FG stu//inessFG ; howe6er, nasalo struction can ha6e ore o scure, nonnasal ani/estations. #o on nonnasal ani/estationso/ o struction include dry outh; chronic sore throat; /rontal, cheek, or or ital $ain indicating

acute or chronic sinusitis; locali ed /acial $ressure indicating sinusitis; e9cessi6e snoringhalitosis; $arental concern a out a child s lethargy or disinterest; ina ility to slee$ soundly tharesults in hy$erso nolence during the day; and decreased sense o/ taste or s ell.Di//erential DiagnosisThe surgeon should ha6e a co $lete list o/ di//erential diagnoses in ind e/ore $roceeding tothe $hysical e9a ination. Syste ic diseases that can cause nasal o struction, such as o esity,hy$othyroidis , !S3HS, and S A gren syndro e, should e e9cluded e/ore $roceeding to the

local e9a ination. E9ternal /actors such as ti$ $tosis, caudal dislocation o/ se$tu , nasal 6al6eo struction, saddle de/or ity, and crooked nose should e e6aluated. 1ntranasal causes o/ nasalo struction include se$tal de6iation, tur inate hy$ertro$hy, and nasal $oly$osis. #hoanal andnaso$haryngeal o struction ay e caused y adenoid hy$ertro$hy, !S3HS, or choanal atresia?Ta le '4.8@. 3lthough no clinical e6idence is a6aila le to docu ent o esity as a cause o/ nasalo struction, it is a co on o ser6ation that $atients with or id o esity ? ody ass inde9greater than "( kg> ' @ ha6e nasal o struction without o 6ious anato ic de/or ities. The $resence o/ syste ic /actors contri uting to nasal o struction is not a contraindication tocorrection o/ identi/ied local areas o/ o struction.


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nasal idline laterally is docu ented. Bony /ractures can de$ress the nasal 6ault and narrow theradius o/ the nasal $assage, and can cause saddle de/or ity. Trau a to the distal u$$er lateralnasal cartilage ?the u$$er lateral wings o/ the Iuadrilateral


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nasal stri$s ?Breathe 2ight, #NS, 1nc., +hi$$any, NJ@ can also result in an i $ro6ed airway, ywidening o/ the nasal 6al6e area in $atients with nasal 6al6e o struction.Ti$


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cause o/ nasal o struction e6en during awake hours. 1denti/ication o/ all areas o/ o struction isessential e/ore $roceeding to the surgical correction o/ a single /actor.1n6estigations1n6estigations to assess nasal airway dys/unction de$end on the sus$ected di//erential diagnosi1n any situations, a thorough history and $hysical e9a ination are adeIuate


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3coustic rhino etry and rhino ano etry ha6e een used to o ecti6ely assess nasal airwayresistance and o struction since the 8KL(s. 2ecently, acoustic rhino etry has ore o/ten eenused in the o ecti6e diagnosis o/ nasal 6al6e o struction. 3coustic rhino etry easures thecross sectional area ?#S3@ o/ the nasal ca6ity, in which a shock wa6e is $resented to the nasairway and the re/lected sound is easured. 2ecent articles descri e the dual ode acousticrhino etry in the diagnosis o/ nasal 6al6e colla$se. 7irst, the #S3 area is easured when the $atient is a$neic, and then the #S3 easure ent is re$eated during the ins$iration. The ratio etween the two is used as a guide to deter ine i/ the $atient has 6al6e colla$se or not. 1n anor al nasal 6al6e, the ins$iratory>a$neic #S3 ratio should e close to 8.(. 3 signi/icant dro$ in#S3 during the ins$iratory $hase will gi6e an ins$iratory>a$neic #S3 ratio o/ less than 8,indicating ins$iratory 6al6e colla$se. 3 6ery low #S3, easured oth in a$nea and ins$iratory

$hase, ay indicate a /i9ed 6al6e o struction. The range o/ nor al #S3, howe6er, is Iuite large,and there/ore any single easure ent is not co $letely diagnostic [email protected] ano etry is a ethod o/ si ultaneous recording o/ the transnasal $ressure and air/low.This techniIue o/ recording $ressure and /low si ultaneously o6er a gi6en ti e inter6al allows/or study o/ the relationshi$ etween $ressure, air/low, and ti e, to gi6e the ost co $leteo ecti6e assess ent o/ the $assage o/ air through the nose. 3lthough hel$/ul as su$$ort data,neither rhino ano etry nor acoustic rhino etry is considered standard in the e6aluation andtreat ent o/ se$tal de/or ity and 6al6e colla$se. Bio$sy is indicated when a neo$las or anunusual in/la atory $rocess, such as /ungal in/ection or +egener granulo atosis, is sus$ected.5anage entThe ost co on thera$ies /or nasal o struction are shown in Ta le '4.'.


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howe6er, ony alteration o/ the $osterior se$tu ?the 6o er or $er$endicular $late o/ theeth oid@ is less /reIuent.


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hy$o$nea syndro e

3s an a$$roach to transse$tal transs$henoidal a$$roach to $ituitary /ossa1ncision


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the se$tu or around the caudal se$tu , de$ending on the e9$osure reIuired. De6iated $ortionso/ the se$tu are identi/ied and re o6ed. 1/ the cartilage is nor al and only a 6entral cartilage,a9illa or 6o er de/or ity is the $ro le , co $lete /la$ ele6ation o/ the contralateral side isnot always essential. 3 kni/e is used to incise the cartilage a o6e the 6entral de/or ity. Se$tals$urs that are due to o6ergrowth o/ the a9illary crest can e re o6ed with a 7reer chisel.2esection o/ 6o er de/or ity can e acco $lished with an osteoto e. #are is taken not to rock the $er$endicular $late o/ eth oid one. 2ocking can cause /racture at the cri ri/or $late andcan cause cere ros$inal rhinorrhea. #are also is taken to a6oid tearing the se$tal /la$s, ecause ilateral tears can cause se$tal $er/oration. !ccasionally, torn ucosa and $erichondriu caninad6ertently e re o6ed with one and cartilage. *oss o/ ucosa will o 6iously delay healingand increase the risk o/ se$tal $er/oration.

7igure '4.8 He itrans/i9ion incision ade on caudal ti$ o/ the se$tu through ucosa and $erichondriu .

7igure '4.' Ele6ation o/ uco$erichondriu /la$ /ro se$tu .+hen de6iation in6ol6es the dorsal strut o/ the se$tu or the caudal end o/ the se$tu , the initiala$$roach is to release the se$tu y e9cision o/ a s all stri$ o/ 6entral cartilage, which ayallow the se$tu to return to a idline $osition. 3n o6erhanging se$tal cartilage ay also eshortened y ini al resection ?' to " @ o/ the caudal se$tu . +ith se6ere de/or ity,e9tended cartilage re o6al ay reIuire cartilage gra/ting to a6oid loss o/ nasal ti$ and dorsalsu$$ort. +hile conser6ing as uch cartilage as $ossi le, the surgeon needs to e wary o/ lea6ingde/or ed cartilage in $lace, which can cause renewed o struction. De/or ed cartilage can ecrushed or scored to reduce the likelihood o/ e ory in the cartilage, which can cause $oor results. 3/ter the cartilaginous structure is /i9ed, se$tal /la$s are a$$ro9i ated with a hori ontalattress ?$licating@ a sor a le suture. 1/ the /ield is not co $letely dry, an incision is adealong the 6entral as$ect o/ the uco$erichondrial /la$, to $ro6ide a drainage site to a6oid a

he ato a. ! 6iously, i/ the /la$ has any tears /ro the ele6ation, this ste$ is unnecessary.Silastic se$tal s$lints can aid in $re6enting synechiae, es$ecially when se$to$lasty has eeco ined with tur inate resection or endosco$ic sinus surgery. The s$lints are held in $lace withsi $le transse$tal suture o/ O ( nylon. S$lints are y no eans, howe6er, essential. The


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he itrans/i9ation incision is closed with two attress sutures o/ " ( chro ic catgut. Nasal $acking is o/ten used to $re6ent the $osto$erati6e se$tal he ato a.Endosco$ic Se$to$lastyThe ad6ent o/ the nasal endosco$e has widened the hori ons o/ otolaryngology. 1ts 6alue ia$$roaching the sinuses, skull ase, or it, and $terygo$alatine /ossa is unIuestiona le. !/tenduring co on nasal $rocedures and during these s$ecial occasions, the surgeon s 6iew iso structed with narrow access due to se$tal s$urs or se$tal de6iations. These occasions dictate locali ed re o6al o/ the s$urs or the de6iation. 1n these situations, the surgeon ay $re/er to usethe endosco$e to assist in locali ed re o6al y aking an incision ust o6er the s$ur ?7ig. '[email protected] /la$ is then ele6ated a o6e and elow the s$ur and the s$ur is re o6ed ?7igs. '4." and '[email protected] the use o/ endosco$e ay li it the surgeon s a ility to use oth hands during surgery,

the ad6antages o/ good 6isuali ation and agni/ication sur$ass its li itation. This techniIue isli ited to locali ed areas o/ o struction due to a s$ur. The incision usually does not need to eclosed.

7igure '4.4 Endosco$ic se$to$lasty: incision is ade o6er the se$tal s$ur under endosco$icguidance.

7igure '4." Endosco$ic se$to$lasty: uco$erichondrial /la$s are ele6ated a o6e and elow these$tal s$ur.


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re o6al, as entioned $re6iously. 1n cases in which there is $ersistence o/ caudal de/lection/ollowing $re6ious se$tal surgery, an o$tion ay e to widen the area y or ital sus$ension o/ the nasal 6al6e ?descri ed later in the cha$ter@, instead o/ ele6ating se$tal /la$s in an area thatalready scarred y $re6ious surgery.+hen re6ision se$to$lasty is essential, the surgeon should /irst $al$ate the se$tu and outlineareas o/ a sent cartilage. The /la$ ele6ation should egin in areas where cartilage or one is $resent. This ay reIuire the use o/ a nonstandard incision ore $osterior to the illian incision.So eti es the incision ay e ade o6er the ony se$tu . !nce /la$ ele6ation isacco $lished, the $rior ste$s o/ re$air are the sa e as standard se$to$lasty.1n co ination with se$to$lasty, nasal /ractures can also e reduced. 1t can e co ined withrhino$lasty, which ser6es as an e9ternal co $li ent. This can e $er/or ed either through the

intranasal or e9ternal route. 2hino$lasty is e9tensi6ely discussed later in the te9t ook.2esultsThe 3 erican 3cade y o/ !tolaryngology Head and Neck Surgery 7oundation ?33! HNS7@ $er/or ed a nationwide study: Nasal ! struction Se$to$lasty E//ecti6eness ?N!SE@ study. Thiswas a ulticenter study $er/or ed in 8" sites, in6ol6ing 8) in6estigators /ro July '((8 throughJanuary 48, '((4. 7i/ty nine $atients underwent nasal surgery. !nly )M o/ $atients re$orted thatthey were not $leased y the $rocedure, and the rest were satis/ied with the i $ro6e ent. Thisi $ro6e ent was unchanged at ) onths.


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He orrhage

Se$tal he ato a>a scess

Synechia

Se$tal $er/oration

3nos ia

E9cessi6e resection o/ dorsal strut can lead to saddle de/or ity

#ere ros$inal /luid /istulas ay result /ro too uch traction on the $er$endicular $late

o/ eth oid one

To9ic shock syndro e is $ossi le, $articularly i/ $acking is used

2are incidences o/ as$iration $neu onitis ha6e een re$orted


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ins$iration or e9$iration. These uttons can e sha$ed to the indi6idual $er/oration and usuallyare well tolerated.2e$air o/ se$tal $er/oration li ited to de/ects less than 4 c in dia eter can e acco $lishedwith surgical /la$s. +ith an intranasal a$$roach, se$tal re$air /reIuently necessitates sliding orrotating uco$erichondrial or $eriosteal /la$s across the de/ect. 7air anks et al. ?4@ ha6edescri ed an ad6ance ent /la$ /or the re$air. Howe6er, large $er/orations cannot e re$airedwith ad6ance ent /la$s.The use o/ an in/erior tur inate /la$ /or se$tal $er/oration re$air has een $u lished y our grou$?"@. 1t essentially in6ol6es the /reshening o/ the argins o/ the $er/oration ?7ig. '4.)@, /ollowe y the har6esting o/ an anterior ased tur inate /la$ under endosco$e guidance. The in/erior hal/ o/ the tur inate actually /or s the donor tissue, and the /la$ includes ucosa, su ucosa, and

6aria le a ounts o/ one de$ending on the si e o/ the tur inate ?7ig. '4.P@. The distal $ortion o/ the /la$ is o$ened to create ucosal sur/ace on one side and su ucosal sur/ace on the other side?7ig. '4.L@. This /la$ is sutured to the /reshened argins o/ the $er/oration ?7ig. '4.K@. Thcontralateral side is le/t o$en /or healing y secondary intention. Three weeks later, the $edicle itaken down, and usually y 4 weeks the contralateral side is also ree$itheliali ed ?7ig. '4.8(@.

7igure '4.) The se$tal $er/oration is ri ed using a no. 8' lade. ?7ro 7ried an 5, 1 rahiH, 2a akrishnan 0. 1n/erior tur inate /la$ /or re$air o/ nasal se$tal $er/oration. *aryngosco$e'((4;884:8"'OFGQ8"'L, with $er ission.@3dditional $rocedures in6ol6e ilateral ucosal ad6ance ent /la$s /reed /ro ad acent se$talcartilage or one, the nasal /loor, and the lateral nasal wall. Surgical re$air o/ large $er/orationsis di//icult, o/ten necessitating e9ternal rhino$lasty or lateral aloto y ?incision along the alarcartilage and a9illary crease@ /or su//icient access to the nasal area. Se$tal $er/oration due tnose $icking o/ten is easy to close, ecause o/ the $reser6ation o/ health ad acent cartilage,whereas $er/oration due to o6er ealous resection o/ se$tal cartilage has a dis al


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7igure '4.P The intended incision site. The anterior attach ent o/ the tur inate is le/t intact.?7ro 7ried an 5, 1 rahi H, 2a akrishnan 0. 1n/erior tur inate /la$ /or re$air o/ nasal se$tal $er/oration. *aryngosco$e '((4;884:8"'OFGQ8"'L, with $er ission.@

7igure '4.L The tur inate /la$ is retracted anteriorly, and the /ree edge is un/olded to slightlye9ceed the si e o/ the $er/oration. ?7ro 7ried an 5, 1 rahi H, 2a akrishnan 0. 1n/erior tur inate /la$ /or re$air o/ nasal se$tal $er/oration. *aryngosco$e '((4;884:8"'OFGQ8"'L, with $er ission.@

7igure '4.K The /la$ is sutured in $lace using $lain " ( catgut. ?7ro 7ried an 5, 1 rahi H,2a akrishnan 0. 1n/erior tur inate /la$ /or re$air o/ nasal se$tal $er/oration. *aryngosco$e'((4; 884:8"'OFGQ8"'L, with $er ission.@Se$tal He ato a and Se$tal 3 scessSe$tal a scess can /ollow se$tal surgery i/ a se$tal he ato a is unnoticed during the initial $osto$erati6e $eriod. 1t should e understood that the se$tal cartilage is a6ascular and recei6es lood su$$ly /ro the adherent uco$erichondriu . !ther causes o/ se$tal a scess include lunttrau a, leeding diathesis, s$orts in ury, and child a use. 1atrogenic se$tal he ato a anda scess /ollowing nasal se$tal surgery are $ro a ly ore co on than they are re$orted. Se$talhe ato a is characteri ed y se6ere locali ed nasal $ain, tenderness on $al$ation o/ the nasalti$, and a cherrylike swelling or luish discoloration o/ the nasal ucosa e anating /ro these$tu , which o structs all or a $ortion o/ the nasal $assage. Se$tal a scesses generally arelarger and ore $ain/ul than unco $licated se$tal he ato a. The o6erlying nasal ucosa isin/la ed and occasionally has in/la atory e9udates. *ocal e9tension o/ the in/ection, i/ le/tuntreated into the ca6ernous sinus with su seIuent intracranial in/ection is the ost serious $otential co $lication. The ost co on co $lication o/ a se$tal a scess is cartilage necrosisthat results in nasal structural colla$se and a saddle nose de/or ity.TechniIue5ost he ato as and a scesses can e adeIuately e6acuated with to$ical anesthesiasu$$le ented y local in/iltration. #on/ir the $resence o/ he ato a y co $ressing the areawith a cotton ti$$ed a$$licator. The ulge


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/ro the he ato a is co $ressi le with the a$$licator. 1t should not shrink with the a$$licationo/ a to$ical 6asoconstrictor.

7igure '4.8( The site o/ $edicle transection ?4 weeks a/ter surgery@ is denoted y the dotted line?7ro 7ried an 5, 1 rahi H, 2a akrishnan 0. 1n/erior tur inate /la$ /or re$air o/ nasal se$tal $er/oration. *aryngosco$e '((4;884:8"'OFGQ8"'L, with $er ission.@3s soon as the diagnosis is con/ir ed, the sutures should e re o6ed and the he ato a should e drained. The clot or the a scess is then e6acuated with suction irrigation i/ needed. 3 ilateralhe ato a can usually e e6acuated /ro one side y gentle $ressure to the contralateral side. 36entral incision along one side o/ the se$tal uco$erichondriu ay hel$ in drainage and ay $re6ent reaccu ulation. 3 wick o/ 8>L inch iodo/or gau e is inserted through the incision. #areshould e taken to ensure that the wick is /lat etween the uco$erichondriu and thecartilaginous se$tu . !ne should not $ack the ca6ity with the wick. This will allow continuousdrainage. 3$$ly ilateral nasal $acks /ollowing the success/ul drainage o/ a se$tal he ato a.


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resection, re o6al o/ redundant ucosa, or oth. 1n/erior tur inecto y /reIuently is co inedwith se$to$lasty to anage contralateral e9acer ation o/ se$tal de6iation. 3lthough in/erior tur inecto y is indicated when ucosal hy$ertro$hy is not res$onsi6e to edication, resectionshould e conser6ati6e. 5or idity associated with radical in/erior tur inate resection includeshe orrhage, o ena, and atro$hic rhinitis. The surgeon ust weigh the e9tent o/ the $ro$osedresection against the nature o/ nasal o struction; longer lasting o struction ay necessitate oree9tensi6e resection.The goals o/ ideal tur inate reduction surgery are cited in Ta le '4.O. n/ortunately, there is nosingle ideal $rocedure /or all $atients. Hence, the surgeon has to choose /ro the array o/ surgical o$tions that are a6aila le and has to select the est $rocedure to address the $athology ina gi6en $atient. The current $rocedures that are ost co only used to treat ony hy$ertro$hy

are ?a@ su ucous resection o/ the in/erior tur inate classical techniIue and ? @ su ucousicrode rider assisted tur inate reduction. The ost co on $rocedure that is now used to treatthe ucosal hy$ertro$hy is radio/reIuency assisted tur inate reduction. The other $roceduresthat are less co only used or that were used in the $ast are ?a@ cryothera$y, ? @ electrocauterand ?c@ laser a lation o/ the in/erior tur inate.3nesthesia5ost o/ these $rocedures can e $er/or ed on an out$atient asis unless they are co ined withother o$erati6e $rocedures, such as se$to$lasty, wherein they can e $er/or ed in the o$eratingroo . 1n an out$atient setting, the $atient is $laced in the sitting $osition. The anterior


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5ucosal $reser6ation

#ontrolled reduction

Su ucous scarring to reduce the erectile nature o/ the ucosa

Bony reduction when necessary

5ini al co $lications

Su ucosal Tur inate 2eduction: #lassical TechniIue#onser6ati6e su ucous tur inate resection, also known as in/erior tur ino$lasty, has eenshown to yield at least 4 to O years o/ relie/ /ro ucosal and ony hy$ertro$hy. Howe6er,su ucosal tur inate resection alone cannot e used to anage nasal o struction, ecause o/ chronic hy$ertro$hy o/ the nasal ucosa. The $hysician ust address the underlying cause o/ ucosal hy$ertro$hy to achie6e good surgical success.Su ucous resection is $er/or ed when the in/erior tur inate $ro ects edially and o structs thenasal ca6ity or when hy$ertro$hic tur inate ucosa re ains unres$onsi6e to 6igorous edicalanage ent. +hen $er/or ed as an isolated $rocedure, in/erior tur inate resection $roceeds

a/ter 6igorous anesthesia and 6asoconstriction o/ the tur inate and lateral nasal wall. 3/ter a $osterior to anterior incision is ade along the in/erior as$ect o/ the in/erior tur inate ?7ig.'4.88@, the uco$eriosteu is ele6ated o// the edial and lateral as$ects o/ the tur inate one.The tur inate one is /ractured and reduced with Jansen 5iddleson rongeur ?7ig. '4.8'@,Takahashi /orce$s, or tur inate scissors. +e $re/er the tur inate scissors. The su$erior andin/erior uco$eriosteal /la$s are care/ully $reser6ed, redundant ucosa is tri ed /ro thein/erior uco$eriosteal /la$, and the su$erior uco$eriosteal /la$ is $laced laterally o6er theresected in/erior tur inate. The uco$eriosteal /la$ is gently $acked in $lace /or '" to "L hourswith anti iotic i $regnated $etrolatu gau e, to ensure $ro$er adhesion and healing o/ theuco$eriosteu to the resected tur inate one. 3n alternati6e is to $lace hori ontal ?$licating@attress sutures through a ini ally resected tur inate, to o 6iate unco /orta le nasal $acking.

7igure '4.88 *i it incision to anterior two thirds o/ tur inate one.


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7igure '4.8' #ottle ele6ator used to ele6ate uco$eriosteu /ro edial, lateral, and in/erior sur/aces o/ tur inate.Su ucosal 5icrode rider 3ssisted Tur inate 2eduction

5ost o/ the techniIues descri ed in6ol6e treat ent o/ su ucous tissue with sacri/ice o/ ucosa/or access to the target area. TechniIues such as $artial or total in/erior tur inecto y,cryosurgery, electrocautery, and laser destroy the ucosa, there y inter/ering with nasal $hysiology. #lassic su ucous resection o/ the in/erior tur inates is a techniIue designed to $reser6e the ucosa, ut it is a isno er ecause the resection includes so e ucosa. The aingoal o/ this ty$e o/ surgery should e the $reser6ation o/ ucosal sur/aces, with reduction o/ thesu ucosal and ony tissue.


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2esults o/ 5icrode rider 3ssisted Tur inate 2eductionStudies conducted y the senior author indicate that out o/ 8'( $atients who underwent thistechniIue, POM had co $lete resolution o/ their sy $to s o/ nasal o struction, and the rest hadso e resolution o/ their sy $to s ?co $lained o/ ini al nasal o struction [email protected] occurred in OM o/ the $atients. None o/ the $atients studied su//ered crusting, /oodor, or nasolacri al duct in ury co $lications ?)@.2adio/reIuency 3ssisted Tur inate 2eductionThe recent ad6ance o/ radio/reIuency energy has gi6en /urther ad6antage /or otolaryngologistin the reduction o/ tur inate hy$ertro$hy. Te $erature controlled radio/reIuency deli6ers acurrent o/ ")( kH , y a high /reIuency alternating current /low into the tissue, creating ionicagitation. This ionic agitation heats the tissue, and as the te $erature rises higher than "P%R#

$rotein coagulation and tissue necrosis ensue. #ollagen de$osition egins a$$ro9i ately 8' daysa/ter in ury, and at 4 weeks, chronic in/la ation, /i rosis, and tissue 6olu e reduction /roscar contracture occur. This can e $er/or ed either y using uni$olar or i$olar radio/reIuency $ro es that can e deli6ered to the anterior, and i/ reIuired, to the iddle as$ects o/ the in/erior tur inate. 3$$ro9i ately 4(( to OO( J o/ energy is deli6ered, and a/ter the $ro e is re o6ed, acotton $ledget with o9y eta oline is $laced along the anterior tur inate /or he ostasis. So ead6ocate a i$olar $ro e as etter in ter s o/ instant tissue reduction, ut no study has clearlyshown that one techniIue is su$erior.2esults o/ 2adio/reIuency 3ssisted Tur inate 2eductionThe $osttreat ent /indings a/ter in/erior tur inate radio/reIuency include nasal swelling /or '"to P' hours. 7inal reduction is co $lete in 4 to " weeks, and retreat ent can e $er/or ed i/ nasal o struction $ersists. Bleeding, crusting, dryness, adhesions, and in/ection are rareco $lications. The ad6antage o/ this $rocedure is that it is less ti e consu ing and oree//icient than other historical $rocedures /or chronic ucosal hy$ertro$hy, such as cryothera$y,electrocautery, and laser a lation. 1t does not reIuire nasal $acking, which is an ad6antage o6esu ucosal icrode rider reduction.#ar on dio9ide laser 6a$ori ation o/ the tur inate had $re6iously een acce$ted as a co ontreat ent /or allergic rhinitis. sually, only a single $rocedure is a$$lied to ini i e trau a.Howe6er, re$eated $rocedures on se$arate days are o/ten reIuired to achie6e an adeIuate e//ectHol iu ?Ho@: ttriu alu inu garnet ? 3 @ laser treat ent is used in the tur inate


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reduction and is e//icacious, ut has $oor long ter e//icacy ?P@.


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colla$se is a co on cause o/ nasal airway o struction. The 6al6e area is co only weakenedsecondary to rhino$lasty, aging, trau a, and other causes. 7i9ed 6al6e o struction ay esecondary to trau a, scarring, $re6ious rhino$lasty, or a narrow 6al6e area secondary to $ersistent caudal se$tal de6iation.

TABLE 23.' EMER&ENCIES NASAL OBSTRUCTIONDiagnosis Eme!gen(y Comp)i(ationsSe$talhe ato a

Ele6ation o/ ucosal $erichondriu with cartilagede6asculari ation

Se$tal cartilage necrosis, de6elo$ ent o/ asaddle nose de/or ity

Se$tal a scess 1ntracranial e9tension o/ in/ectionSe$tal cartilage necrosis, de6elo$ ent o/ asaddle nose de/or ity, ca6ernous sinusthro osis, intracranial in/ection

5ucor ycosis Tissue destruction E9tension to rain or or itSurgical reconstruction o/ an inco $etent nasal 6al6e can e undertaken with an o$en a$$roachthat allows clear assess ent o/ o$erati6e aug entations. The ost success/ul o$erati6etechniIues include syste atic alteration o/ all surrounding 6al6e s$reader cartilage gra/ts?widening the a$e9 i/ the internal 6al6e@; suture re$air o/ the droo$ing u$$er lateral cartilage/reIuent co $lication a/ter dorsal hu $ e9cision in rhino$lasty@, autogenous cartilage gra/ts, orallogra/ts as needed to su$$ort the colu ella; and s$anning gra/ts or si $le lateral crus onlaygra/ts to su$$ort the lateral crura ?8(@. ra/ts can e co $osed o/ cartilage or conchal one /ro

concurrent in/erior tur inecto y. The ony or cartilaginous gra/t ser6es as oth an inherentstructural su$$ort and a ethod /or inducing site s$eci/ic scarring, which enhances the sti//nesso/ this region. The results o/ these techniIues are Iuite 6aria le and de$end on the surgeon se9$erience. The co $lications o/ o$en $rocedure range /ro he ato a to gra/t re ection ?Ta le'4.)@. 5ost o/ these co $lications are si ilar to o$en rhino$lasty.


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e9ternal 6al6e area ?7igs. '4.8P and '4.8L@. !ccasionally, two one anchors and /our $oints o//i9ation are needed /or adeIuate correction.

7igure '4.84 1ntranasal incision connecting the two sides o/ sus$ension to allow /or

su cutaneous>su ucosal $lace ent o/ suture. The incision was not closed. ?7ro 7ried an 5,1 rahi H, *ee , Jose$h NJ. 3 si $li/ied techniIue /or airway correction at the nasal 6al6earea. !tolaryngol Head Neck Surg '((";848:O8KFGQO'", with $er ission.@

7igure '4.8" 1ncision site: 4 $laced in skin crease. ?7ro 7ried an 5, 1 rahi 1, Syed V. Nasal 6al6e sus$ension: an i $ro6ed, si $li/ied techniIue /or nasal 6al6e colla$se.*aryngosco$e '((4;884:4L8FGQ4LO, with $er ission.@

7igure '4.8O 5edial to the intraor ital ner6e and slightly elow in/raor ital ri , the anchor isdrilled. ?7ro 7ried an 5, 1 rahi 1, Syed V. Nasal 6al6e sus$ension: an i $ro6ed, si $li/iedtechniIue /or nasal 6al6e colla$se. *aryngosco$e '((4;884:4L8FGQ4LO, with $er ission.@#o $licationsThe ost co on co $lication /ollowing the $rocedure is the /oreign ody reaction to the5itek anchor syste . So eti es, a scesses can /or o6er the incision site. This reIuiresas$iration o/ the a scess, which should e su ected to culture and sensiti6ity and treated withthe a$$ro$riate anti iotic. 1n other cases, granulo a /or ation has een known to occur. 1n OMo/ these $atients, suture re o6al is reIuired. !ther, less co on co $lications includehe ato a /ollowing in ury to the angular 6ein during $lace ent o/ the anchor into the a9illarysinus ?Ta le '4.)@.2esults!ur e9$erience with the or ital sus$ension techniIue was /ro '((8 to '((". 3ll $atients hadinor changes in their e9ternal a$$earance that were either considered an i $ro6e ent or inconseIuential. Nearly all $atients ?K8.PM@ had signi/icantly i $ro6ed airways in a short terstudy. The only co $lication re$orted was the /oreign ody reaction /ollowing the $rocedure thate6entually reIuired re o6al. *ong ter results are not a6aila le ?84@.#hoanal 3tresia#hoanal atresia is a genetic disorder in which the $osterior choanae unilaterally or ilaterally /aito de6elo$ $ro$erly. 1t occurs in 8 in O,((( irths; choanal atresia is ore


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co on a ong girls ?':8@, and unilateral atresia is ore co on than ilateral atresia. Thisdisorder can e trans itted as an autoso al recessi6e trait ?8"@. Because new orns are o ligatenose reathers, ilateral atresia is i ediately a$$arent as res$iratory distress. 3n endotrachealtu e is inserted, and the in/ant is e9a ined. #haracteristics in the history that are /ound at /ailureto $ass a ru er catheter or nasogastric tu e into the $haryn9 can $ro6ide enough in/or ation /or a diagnosis. Sy $to s o/ choanal atresia include /ailure to thri6e due to $oor /eeding anducoid discharge /ro the a//ected side. The $resence o/ choanal atresia can e con/ir ed with6isuali ation o/ retention aterial in the $osterior $art o/ the nose on a lateral radiogra$h withthe $atient in the su$ine $osition. 3nato ic characteri ation o/ the de/or ity with #T scanningcan e i $ortant /or $lanning surgical $rocedures.

7igure '4.8) 3/ter identi/ying the colla$se site and the intended sites o/ the suture sus$ension,the cur6ed needle is $assed through the incision and the su cutaneous tissue into the nose. ?7ro7ried an 5, 1 rahi 1, Syed V. Nasal 6al6e sus$ension: an i $ro6ed, si $li/ied techniIue /or nasal 6al6e colla$se. *aryngosco$e '((4;884:4L8FGQ4LO, with $er ission.@

7igure '4.8P


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$ro6ide enough in/or ation /or the diagnosis. Trans$alatal re$air is eing re$laced yendosco$ic techniIues o/ re$air o/ atresia in children and adults [email protected]

Nasal o struction is one o/ the ost co on sy $to s in otolaryngologic $ractice. 1nthe nited States, edical e9$enditures to relie6e nasal o struction or congestiona$$ro9i ate WO illion annually.

1t is crucial to recogni e that nasal se$tal de/or ity is not the only cause /or o struction.

Syste ic diseases, nasal 6al6e o struction, tur inate hy$ertro$hy, $oly$s, and neo$lasare other co on causes.

1n addition to the history, $hysical e9a ination o/ the nose y eans o/ direct and

endosco$ic 6isuali ation discloses ost cases o/ nasal o struction and allowscon/ir ation through tests /or co on causes o/ nasal o struction.

#o $uted to ogra$hy o/ the sinuses without contrast aterial is the ost hel$/ul

au9iliary e9a ination /or e6aluating nasal o struction.

There is no uni6ersally acce$ted /unctional test o/ nasal o struction. 3coustic rhino etry

is $ro ising in identi/ication o/ ins$iratory nasal 6al6e colla$se.

Se$tal he ato a and a scess are the two causes o/ nasal o struction that necessitate

e ergency anage ent.

Se$tal correction o//ers e//ecti6e sy $to atic relie/ in cases o/ arked se$tal de6iation.

5ucosal tur inate hy$ertro$hy can e e//ecti6ely anaged y radio/reIuency reduction;

ony or i9ed tur inate hy$ertro$hy can e reduced y icrode rider assisted reduction.

Nasal 6al6e colla$se can e e//ecti6ely treated with naso or ital sus$ension, as well as

other techniIues.


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Bilateral choanal atresia is a edical e ergency in in/ants and needs i ediate

diagnosis and anage ent.


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bailey words

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