Desviación septal nasal en relación con las deformidades nasales externas: un estudio observacional / Nasal septal deviation in relation to external nasal deformities: an observational study

La nariz es estructuralmente compleja, y esta complejidad da como resultado variaciones de forma nasal. El estudio tuvo como objetivo determinar las desviaciones septales nasales que ocurren en relación con las deformidades nasales externas. Se realizó un estudio transversal en el departamento de oído, nariz y garganta, en nuestro hospital. Todos los individuos que tienen desviación septal con deformidad nasal externa de noviembre de 2017 a noviembre de 2018. Esos pacientes serán evaluados mediante un examen clínico integral de la oreja, la nariz y la garganta. Los síntomas del paciente se clasifican con el cuestionario de prueba china nasal -22. Las deformidades septales se clasificaron utilizando la clasificación Mladina modificada. Las deformidades nasales externas se clasificaron empleando la clasificación de Yong Jo Jang. Aproximadamente, el 43% eran hombres y el 57% eran mujeres. Alrededor del 90% de los pacientes de 21 años a 50 años. Alrededor del 58% de los pacientes eran sintomáticos, mientras que el resto del 42% no tenía síntomas. Al correlacionar los síntomas con el tipo de desviación, se encontró significativamente asociación (P = 0.05). La mayoría de las personas se encuentran en el grupo de mediana edad. Tipo II y IV son los tipos más comunes de NSD, mientras que el tipo I es un final común. El encuentro notable de nuestro estudio es que los pacientes no tenían deformidad

The nose is structurally complex, and this complexity results in nasal shape variations. The study aimed to determine the nasal septal deviations occurrence in relation to external nasal deformities. A crosssectional study was conducted in Department of Ear, Nose and Throat, in our hospital. All the individuals having septal deviation with external nasal deformity from November 2017 to November 2018. Those patients be evaluated by comprehensive clinical examination of ear, nose and throat. Patient's symptoms are rated with Sino-Nasal Test -22 questionnaire. Septal deformities were classified using Mladina classification modified. External nasal deformities were classified employing Yong Jo Jang's classification. Approximately, 43% were males and 57% were females. About 90% of patients aged from 21 years to 50 years. About 58% of patients were symptomatic while the rest 42% were without symptoms. On correlating the symptoms with the type of deviation it was found significantly association (P=0.05). Majority of individuals are in the middle age group. Type II and IV are the most common types of NSD whereas type I is a common END. Noteworthy finding of our study is patients had no deformity.

Diferentes técnicas para colocação de enxerto de extensão caudal em rinoplastia / Different techniques for caudal extension graft placement in rhinoplasty

Resumo Introdução: O enxerto de extensão caudal é geralmente um enxerto de cartilagem que se sobrepõe à margem caudal do septo nasal. Uma combinação do enxerto de extensão caudal e a técnica de tongue-in-groove é usada para estabilizar a base nasal, definir a projeção da ponta e refinar a relação alar-columelar. Objetivo: Apresentar algumas novas modificações na colocação dos enxertos de extensão caudal na rinoplastia. Método: Revisão retrospectiva de um banco de dados prospectivamente coletado de 965 pacientes que se submeteram a rinosseptoplastia de junho de 2011 a julho de 2015. Desses, 457 pacientes necessitaram de enxerto de extensão caudal e foram incluídos no estudo. O seguimento mínimo foi de 13,2 meses, com tempo médio de seguimento de 17,4 meses. Resultados: Na maioria dos casos, a comparação das fotografias antes e após a cirurgia foi satisfatória e apresentou melhora do contorno. Pequenas deformidades foram detectadas em 41 pacientes e 11 pacientes necessitaram de cirurgia de revisão. Conclusão: Com essas modificações, o cirurgião pode usar o enxerto de extensão caudal mesmo em desvios angulares do septo caudal. Vários métodos têm sido propostos para correção do desvio septo-caudal.

Algorithm for the treatment of external nasal valve insufficiency / Algoritmo para o tratamento da insuficiência de válvula nasal externa

Abstract Introduction: Nasal obstruction is one of the most prevalent complaints in the population. The main causes of nasal obstruction are inflammatory, infectious or anatomical alterations. Anatomical alterations include nasal septum deviation, turbinate hypertrophy, and nasal valve insufficiency (external and/or internal). The diagnosis of nasal valve insufficiency remains a clinical one and is based on inspection and palpation of the nose, evaluating both its static and dynamic functions. The literature presents several options for the correction of external nasal valve insufficiency. These are chosen according to the choice and experience of each surgeon. Objective: To create a practical algorithm for the treatment of external nasal valve insufficiency that can guide nasal surgeons in their choice of treatment for the different anatomical alterations found in patients with these disorders. Methods: We used the treatment options found in the literature and correlated them with our surgical options for each type of anatomical alteration found. Therefore, we used basically three parameters related to physical examination findings (degree of insufficiency and characteristics of the lower lateral cartilage) and the patient's complaint (present or absent aesthetic complaint regarding the nasal tip). Result: A practical algorithm was developed for the treatment of external nasal valve insufficiency according to the degree of insufficiency (mild-to-moderate or severe), aesthetic complaint of the nasal tip (present or absent) and characteristics of the lower lateral cartilage (size and orientation). Conclusion: Through this simple algorithm, one can use each type of graft and/or maneuver according to the patients' complaints and the anatomical alterations found.

Resumo Introdução: A obstrução nasal é uma das queixas mais prevalentes na população. As principais causas de obstrução nasal são inflamatórias, infecciosas ou alterações anatômicas. As alterações anatômicas incluem: desvio do septo nasal, hipertrofia de conchas nasais e insuficiência da válvula nasal (externa e/ou interna). O diagnóstico da insuficiência de válvula nasal permanece clínico e baseado na inspeção e palpação do nariz, avaliado em funções estática e dinâmica. Temos na literatura diversas opções de correção da insuficiência de válvula nasal externa. Essas são escolhidas de acordo com a opção e experiência de cada cirurgião. Objetivo: Criar um prático algoritmo para o tratamento da insuficiência de válvula nasal externa, que oriente os cirurgiões de nariz na escolha do tratamento para as diferentes alterações anatômicas encontradas nos pacientes portadores dessas alterações. Método: Utilizamos as opções de tratamento encontradas na literatura e relacionamos com as nossas opções cirúrgicas para cada tipo de alteração anatômica encontrada. Dessa forma, utilizamos basicamente três parâmetros relacionados aos achados de exame físico (grau de insuficiência e características da cartilagem lateral inferior) e à queixa do paciente (queixa estética da ponta nasal presente ou ausente). Resultado: Um algoritmo prático para o tratamento da insuficiência de válvula nasal externa, de acordo com o grau da insuficiência (leve-moderada ou severa), a queixa estética da ponta nasal (presente ou ausente) e as características da cartilagem lateral inferior (tamanho e orientação). Conclusão: Através desse simples algoritmo, podemos utilizar cada tipo de enxerto e/ou manobra de acordo com as queixas dos pacientes e as alterações anatômicas encontradas.

Techniques in the safe use of polycaprolactone in structural rhinoplasty

@#<p><strong>Structural Rhinoplasty</strong> is a term use by rhinoplastic surgeons wherein the existing structures are reconstructed and strengthened for functional and aesthetic improvement of the nose. The function refers mainly to breathing by correcting septal deviation and enlarging the internal valves.1</p><p>The usual surgical method is open rhinoplasty approach and all anatomical structures are analyzed. The central septal cartilage is removed while the remaining dorsal and caudal strut are reconstructed for better breathing and tip support.2 The general concept is to alter the length and height of the existing dorsal and caudal strut by restructuring with the use of the central harvested cartilage. Cartilages used for strengthening the struts are called structural grafts while cartilages used for tip reshaping and projection are called contour grafts.3</p><p>Structural grafts commonly include the columellar strut graft, septal extension graft (SEG), spreader graft or extended spreader graft (ESG).1 The columellar strut and SEG are used for lower cartilage and tip support. The spreader graft is used for strengthening the dorsal strut and enlarging the internal valve. The ESG is a spreader graft that is extended beyond the anterior angle of the septum for support of lower cartilage and tip. Among the structural grafts for lower cartilage tip support it is the Septal Extension Graft (SEG) that gives the best longevity.4 The SEG is either placed side-to-side to the caudal strut or end-to-end supported by bilateral extended spreader graft (ESG). (Figures 1 & 2) Sometimes, a combination of ESG with SEG is needed to correct weakness of the struts. (Figure 3) Contour grafts are usually the dorsal graft and tip grafts. (Figure 4)</p><p>Because Asian (specifically South East Asian) noses are usually small, the harvested septum is often small and soft.3,4 Occasionally, the septum may look strong but upon harvest the dorsal and caudal struts weaken. Additional cartilage grafts are usually needed either from the auricle or from the rib. Auricular cartilage is too soft as support graft while the rib cartilage is strong because of its resemblance to septum in its histology. Autologous rib rhinoplasty is not only tedious and invasive but also more expensive which most patients do not prefer. Because of the paucity of septum, there are many substitute commercial materials in the market which can simulate the strength of septal cartilage as support graft. These can be homologous processed human rib cartilage, or alloplastic non-absorbable porous polyethylene. These materials are prone to long term complications e.g. warping, fracture, infection, resorption and extrusion.5,6 Scientists and bioengineers recently developed polycaprolactone (PCL) which is a new synthetic absorbable porous material. It is marketed as a better material because not only it gives support but it also serves as a scaffold for tissue regeneration.7-9</p><p>Polycaprolactone (PCL) is an absorbable material used in craniomaxillofacial surgery as a scaffold for defects.10 It is absorbed completely in 2 years. It is also a material used as threads in facial rejuvenation.11-13 Recently, PCL has been fashioned into mesh for use in septoplasty and rhinoplasty as implants and support.14,15 Its use is mainly as a scaffold for tissue regeneration and support. It has been shown in studies that osteoblasts, chondroblasts and mesenchymal tissues grow into its pores.10, 15 It comes in various shapes and sizes. The ideal ones for use in nasal surgery are the 10 mm x 30-40 mm mesh plate with thickness variety of 0.8-1.2 mm. (Figure 5)</p><p>Polycaprolactone is not used routinely; it is still best to use all autologous tissues. The indication of the use of PCL depends on the structure of the nose (mainly the septum). It is best for use in cases of small septum with inadequate septal material for correction of deviation. It is also best for use in cases of weak septum or weak dorsal/ caudal struts after septal harvest to correct any possibility of collapse. Moreover, PCL is not advisable in severe contracted nose because forces of healing may lead to wound dehiscence, extrusion and infection. Extrusion and infection may also happen while PCL is still not completely absorbed in 2 years. </p><p>Since PCL is noted to lose its strength but provide well as a template for tissue regeneration, it is recommended to cover the PCL with septal or conchal cartilages whenever possible for 2 reasons: firstly, for protection against mucosal erosion; and secondly, as cartilage regeneration template for future support. (Figure 6). The decision to use PCL is made intraoperatively. The PCL mesh is fashioned into either an end-to-end SEG or ESG; both techniques of grafting are covered majority with cartilages. Following is the algorithm showing the indications when to use PCL after open rhinoplasty approach and assessment of the strength of the septum:</p><p>There are times wherein minimal surgery is needed for tip projection. Since Asian noses have weak medial crura with heavy skin and soft tissue envelope, PCL can be used just as a columellar strut - either floating or fixed to the posterior caudal septum. Fixing to the posterior caudal septum functions similar to a SEG too. However, these techniques may be unstable. (Figures 12 & 13)</p><p>Polycaprolactone was commercially available locally in the latter part of 2018. From August 2018 to March 2020, I used PCL in 213 (40.7%) out of 523 cases of septoplasty for structural rhinoplasty for various indications. All outcomes were followed up through calls and/or texts and all results were good with all patients satisfied with their results as of this writing, except for two. One patient developed post-operative deviation of the SEG after a week; the etiology was due to the improper choice of PCL strength. Revision surgery was done with replacement by a thicker PCL. Another patient developed infection after 4 months. Revision surgery involved removal of PCL and placement of columellar strut for support. This initial experience with the use of PCL is promising but it is too early to conclude. Long term follow-up should be done to see changes in structure when the PCL is totally absorbed.</p><p>In summary, PCL is a strong absorbable tissue template mesh in septoplasty and rhinoplasty. It is gradually absorbed within 2 yrs. While it is in its early stage as a mesh graft, it gives strength. However, as it is slowly absorbed, it imbibes the surrounding tissue cells for regeneration for future strength. It is highly recommended to cover the PCL with cartilages to prevent erosion to surrounding mucosa. Aside from protection of the PCL against erosion and extrusion, the cartilage also gives the future strength as chondrocytes grow into the PCL mesh.</p>

Resultados posoperatorios de cierre quirúrgico de perforación septal con injertos de cartílago / Surgical outcomes of nasal septal perforation repair with cartilage grafts

Introducción: las perforaciones septales y su corrección quirúrgica constituyen un reto para los otorrinolaringólogos. En la literatura se describen diferentes técnicas para el cierre de las perforaciones septales; sin embargo, sus resultados en términos de efectividad son muy variables y con pocos pacientes. Desde hace 8 años se viene realizando la técnica de cierre de perforación septal con injertos de cartílago en el servicio de otorrinolaringología del Hospital de San José, y se ha observado una respuesta clínica exitosa. El objetivo del presente estudio fue describir los resultados posoperatorios de los pacientes manejados con la técnica de cierre quirúrgico de perforación septal con injertos de cartílago, en términos de aparición de complicaciones y frecuencia de perforación septal residual. Materiales y métodos: mediante un estudio de cohorte descriptiva se presentan los pacientes manejados con la técnica de cierre quirúrgico de perforación septal con injertos de cartílago de banco o cartílago autólogo. Se incluyen pacientes a partir enero de 2014 a junio 2018. De la historia clínica se extrajeron los datos demográficos, clínicos, complicaciones y presentación de perforación septal residual. Resultados: la tasa de éxito de cierre de perforación septal fue de 78,3 %; siendo las etiologías más frecuentes antecedente de cirugía e idiopática. La complicación más común fue epistaxis en el 26 % de los pacientes, seguida de dolor en el 21,7 % en el posoperatorio mediato, el cual mejoró en los controles posteriores. Conclusión: los resultados con la técnica de cierre de perforación septal con injerto de banco fueron satisfactorios en esta población.

Introduction: septal perforations and surgical correction are a challenge for ENT specialists. Several techniques for closing septal perforations are described in the literature; however, its results in terms of effectiveness are variable and with small sample sizes. The technique of closure of septal perforation with cartilage grafts has been performed for 8 years in the ENT department of Hospital de San José with a successful clinical response. Aims: to describe the postoperative results of patients managed with the technique of surgical closure of septal perforation with cartilage grafts, in terms of complications and frequency of residual septal perforation. Design: descriptive cohort study. Methods: a cohort of patients managed with the surgical closure technique of septal perforation with grafts of bank cartilage or autologous cartilage are described. Patients were included from January 2014 to June 2018. Demographic, clinical data, complications and presentation of residual septal perforation were extracted from the clinical history. Results: The success rate of septal perforation closure was 78.3 %; being the most frequent etiologies antecedent of surgery and idiopathic. The most common complication was epistaxis in 26 % of patients, followed by pain in 21.7 % in the postoperative period, which improved in subsequent controls. Conclusion: the results with the technique of closure of septal perforation with bank grafting were satisfactory in this population.

Rinomodelação ou rinoplastia não-cirúrgica: uma abordagem segura e reprodutível / Rhinomodelation or non-surgical rhinoplasty: a safe and reproducible approach

Introdução: A rinoplastia é uma cirurgia que muitas vezes apresenta resultados imprevisíveis, mesmo em mãos de cirurgiões experientes. Neste sentido, a rinomodelação com preenchedores é um procedimento não-cirúrgico para corrigir pequenas alterações externas nasais em casos específicos. Métodos: Os autores descrevem a técnica de aplicação de preenchedores (ácido hialurônico ou hidroxiapatita de cálcio) para modelação nasal. Foram incluídos todos os pacientes submetidos ao preenchimento nasal, entre 2009 e 2012. Foi avaliado o edema da ponta nasal, a dor e o grau de satisfação dos pacientes com o resultado. Resultados: Foram incluídos 39 pacientes no estudo. Com relação aos desfechos analisados com ácido hialurônico: 52% apresentaram edema leve; 74% tiveram dor leve; 15% se mostraram muito satisfeitos e 74% satisfeitos com o resultado. Com relação aos pacientes submetidos à rinomodelação com hidroxiapatita de cálcio: 67% apresentaram edema moderado; 50% dor moderada; 17% dor intensa e 84% se mostraram satisfeitos com o resultado. Conclusão: A rinomodelação com preenchedores reabsorvíveis é um procedimento simples, com resultados estéticos aceitáveis, sendo necessário um profundo conhecimento anatômico para diminuir o risco de complicações.

Introduction: Rhinoplasty often leads to unpredictable results, even in the hands of experienced surgeons. However, in specific cases, rhinomodelation with fillers, a non-surgical procedure to correct minor nasal external changes, can be used. Methods: This study describes the application technique of fillers (hyaluronic acid or calcium hydroxyapatite) for nasal modeling. Patients undergoing nasal filling between 2009 and 2012 were included. Edema of the nasal tip, pain, and the degree of patient satisfaction with the outcome were assessed. Results: Thirty-nine patients were included in the study. Regarding the outcomes of rhinomodelation with hyaluronic acid, 52% patients presented with mild edema, 74% had mild pain, 15% were very satisfied, and 74% were satisfied with the result. For the outcomes of rhinomodelation with calcium hydroxyapatite, 67% patients presented with moderate edema, 50% had moderate pain; 17% had severe pain, and 84% were satisfied with the result. Conclusion: Rhinomodelation with resorbable fillers is a simple procedure with acceptable esthetic results. However, a deep anatomical knowledge is necessary to decrease the risk of complications.

Resultados postoperatorios de cierre quirúrgico de perforación septal con injertos de cartílago / Surgical outcome of nasal septal perforation repair with cartilage grafts

Introducción: las perforaciones septales y su corrección quirúrgica constituyen un reto para los otorrinolaringólogos. Se encuentran descritas en la literatura diferentes técnicas para el cierre de las perforaciones septales; sin embargo, sus resultados en términos de efectividad son muy variables y con pocos pacientes. Desde hace 8 años se viene realizando la técnica de cierre de perforación septal con injertos de cartílago en el servicio de otorrinolaringología del Hospital San José y se ha observado una respuesta clínica exitosa. Objetivo: describir los resultados postoperatorios de los pacientes manejados con la técnica de cierre quirúrgico de perforación septal con injertos de cartílago, en términos de aparición de complicaciones y frecuencia de perforación septal residual. Diseño: estudio de tipo cohorte descriptiva. Metodología: se describe una cohorte de pacientes manejados con la técnica de cierre quirúrgico de perforación septal con injertos de cartílago de banco o cartílago autólogo. Se incluyeron pacientes a partir de enero de 2014 a junio de 2018. Se extrajeron de la historia clínica los datos demográficos, clínicos, complicaciones y presentación de perforación septal residual. Resultados: la tasa de éxito de cierre de perforación septal fue de 78,3 %; siendo las etiologías más frecuentes antecedente de cirugía e idiopática. La complicación más común fue epistaxis en el 26 % de los pacientes, seguida de dolor en el 21,7 % en el postoperatorio mediato, el cual mejoró en los controles posteriores. Conclusión: los resultados con la técnica de cierre de perforación septal con injerto de banco fueron satisfactorios en esta población.

Introduction: septal perforations and surgical correction are a challenge for ENT specialists. Several techniques for closing septal perforations are described in the literature; however, its results in terms of effectiveness are very variable and with small sample sizes. The technique of closure of septal perforation with cartilage grafts has been performed for 8 years in the ENT department of San José Hospital with a successful clinical response. Aims: to describe the postoperative results of patients managed with the technique of surgical closure of septal perforation with cartilage grafts, in terms of complications and frequency of residual septal perforation. Design: descriptive cohort study. Methods: a cohort of patients managed with the surgical closure technique of septal perforation with grafts of bank cartilage or autologous cartilage are descrived. Patients were included from January 2014 to June 2018. Demographic, clinical data, complications and presentation of residual septal perforation were extracted from the clinical history Results: The success rate of septal perforation closure was 78.3%; being the most frequent etiologies antecedent of surgery and idiopathic. The most common complication was epistaxis in 26% of patients, followed by pain in 21.7% in the postoperative period, which improved in subsequent controls. Conclusion: the results with the technique of closure of septal perforation with bank grafting were satisfactory in this population.

Comparative Analysis of Endonasal Lateral Osteotomy and Percutaneous Lateral Osteotomy in Patients with Deviated Nose / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The purpose of this study was to compare the effectiveness of percutaneous and endonasal lateral osteotomy for the correction of deviated nose. SUBJECTS AND METHOD: Medical records of 60 patients who underwent rhinoplasty to correct deviated nose were reviewed retrospectively. Patients with unilateral osteotomy, revision rhinoplasty, spreader graft, or who had no preoperative or postoperative photos were excluded from the study. The patients were categorized into two groups, which either had C-shaped deviation or I-shaped deviation. Preoperative and postoperative deviation angles were measured and their differences were analyzed according to the approach methods. RESULTS: In the percutaneous approach group, 26 patients had C-shaped deviation and 10 patients had I-shaped deviation, whereas in the endonasal approach group, 17 patients had C-shaped deviation and 7 patients had I-shaped deviation. In the percutaneous approach, the deviation angle was statistically improved in the C-shaped deviation, but in the endonasal approach, it was statistically improved in the C-shaped and I-shaped deviation after surgery. In the C-shaped deviation, the average degrees of improvement of percutaneous and endonasal approach were 5.2°±3.6° and 7.9°±5.3°, respectively, which showed significant difference. However, in the I-shaped deviation, the average degrees of improvement of percutaneous and endonasal approach were 2.9°±1.3° and 2.9°±1.0°, respectively, with no significant difference. CONCLUSION: The improvement of deviation angle following osteotomy may be different according to the approach methods for deviated nose. Endonasal approach was more suitable than percutaneous approach in the correction of I-shaped deviated nose.

Disease-specific quality of life after septoplasty and bilateral inferior turbinate outfracture in patients with nasal obstruction / Qualidade de vida específica da doença após septoplastia e fratura bilateral de concha inferior em pacientes com obstrução nasal

Abstract Introduction: Septal deviations might cause nasal obstruction and negative impact on the quality of life of individuals. The efficacy of septoplasty for treatment of septal deviation and the predictors of satisfactory surgical outcomes remain controversial. Technical variability, heterogeneity of research samples and absence of a solid tool for clinical evaluation are the main hindrances to the establishment of reliable statistical data regarding the procedure. Objective: To evaluate the clinical improvements in the disease-specific quality-of-life between patients submitted to septoplasty with bilateral outfracture of the inferior turbinate under sedation and local anesthesia in a tertiary hospital and to assess possible clinical-epidemiological variables associated with functional outcome. Methods: Fifty-two patients consecutively submitted to septoplasty with bilateral outfracture of the inferior turbinate for treatment of nasal obstruction filled in forms regarding clinical and epidemiological information during enrollment and had their symptom objectively quantified using the Nose Obstruction Symptom Evaluation (NOSE) scale preoperatively and one and three months after the procedure. Statistical analysis aimed to determine overall and stratified surgical outcomes and to investigate correlations between the clinical-epidemiological variables with the scores obtained. Results: Statistically significant improvement in the preoperative NOSE questionnaire compared to the scores obtained three months after surgery was demonstrated (p < 0.001, T-Wilcoxon), with strong correlation between the preoperative score and the postoperative improvement during this period (r = −0.614, p < 0.001, Spearman). After one month, patients reached in average 87.15% of the result obtained at the study termination. Smokers and patients with rhinitis and/or pulmonary comorbidity showed increased average preoperative NOSE scores, although without statistical significance (p > 0.05). Gender, age, history of rhinitis and presence of pulmonary comorbidity did not influence significantly surgical outcomes (p > 0.05). Smokers presented greater reduction in NOSE scores during the study (p = 0.043, U-Mann-Whitney). Conclusion: Septoplasty with bilateral outfracture of the inferior turbinate has proven to significantly improve disease-specific quality-of-life and this favorable outcome seems to occur precociously.

Resumo Introdução: Os desvios septais podem causar obstrução nasal e impacto negativo na qualidade de vida dos indivíduos. A eficácia da septoplastia para o tratamento do desvio septal e os preditores de resultados cirúrgicos satisfatórios continuam controversos. A variabilidade técnica, a heterogeneidade das amostras de estudo e a ausência de uma ferramenta sólida para avaliação clínica são os principais obstáculos ao estabelecimento de dados estatísticos confiáveis sobre o procedimento. Objetivo: Avaliar a melhora clínica na qualidade de vida específica da doença entre pacientes submetidos a septoplastia e fratura bilateral da concha inferior sob sedação e anestesia local em um hospital terciário e possíveis variáveis clínico-epidemiológicas associadas ao desfecho funcional. Método: Cinquenta e dois pacientes consecutivamente submetidos a septoplastia e fratura bilateral da concha inferior para o tratamento da obstrução nasal preencheram formulários com informações clínicas e epidemiológicas durante a inclusão no estudo e tiveram seus sintomas quantificados objetivamente utilizando a escala de Avaliação de Sintomas de Obstrução Nasal (Nose Obstruction Symptom Evaluation - NOSE) no pré-operatório e um e três meses após o procedimento. A análise estatística objetivou determinar resultados cirúrgicos globais e estratificados e investigar correlações entre as variáveis clínico-epidemiológicas e os escores obtidos. Resultados: Foi demonstrada uma melhora estatisticamente significativa nos escores obtidos no questionário NOSE três meses após a cirurgia (p < 0,001, T-Wilcoxon), quando comparado com os escores obtidos no pré-operatório, com uma forte correlação entre o escore pré-operatório e a melhora pós-operatória durante esse período (r = -0,614, p < 0,001, Spearman). Após um mês, os pacientes atingiram em média 87,15% do resultado obtido ao término do estudo. Fumantes e pacientes com rinite e/ou comorbidade pulmonar apresentaram valores médios pré-operatórios do escore NOSE aumentados, embora sem significância estatística (p > 0,05). Sexo, idade, história de rinite e presença de comorbidade pulmonar não influenciaram significativamente os resultados cirúrgicos (p > 0,05). Os fumantes apresentaram maior redução nos escores de NOSE (p = 0,043, U-Mann-Whitney). Conclusão: A septoplastia e a fratura bilateral da concha inferior demonstraram melhorar significativamente a qualidade de vida específica da doença e este resultado favorável parece ocorrer de forma precoce.

Avaliação da modificação da técnica de reconstrução das cartilagens alares de Max Pereira no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre / Evaluation of Max Pereira alar reconstruction technique modification in the total nasal reconstruction protocol of the Hospital of Clinics of Porto Alegre

Introdução: A reconstrução nasal é a mais antiga das cirurgias plásticas. A anatomia nasal é complexa e necessita de uma associação de técnicas para a restauração da função e estética nasal adequada. Pereira et al. descreveram uma técnica que possibilita a reconstrução nasal total da cartilagem alar, com o uso de um enxerto da cartilagem auricular, com mínima deformidade auricular secundária à retirada do enxerto. O objetivo deste trabalho é apresentar uma modificação da técnica acima descrita, que possibilita reconstruir mais uma região anatômica do nariz, sem aumentar a morbidade, realizada por Collares et al., e a sua inserção no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre. Métodos: Foi realizado um estudo retrospectivo. Avaliou-se a inserção da modificação da técnica em 10 pacientes que realizaram reconstrução nasal total. Resultados: Após a análise dos 10 casos, utilizando a modificação da técnica inserida no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre, encontramos uma melhoria da forma do nariz, a válvula nasal interna com preservação da função e sem sequelas secundárias à retirada do enxerto auricular. Conclusão: Nesta série de casos, a modificação da técnica de Max Pereira resultou em tratamento estético funcional adequado quando implementada no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre, sem aumentar a morbidade na área doadora.

Introduction: Nasal reconstruction is the oldest plastic surgery technique. The nasal anatomy is complex and requires an association of techniques for the restoration of function and adequate nasal esthetics. Pereira et al. described a technique that allows total nasal reconstruction of the alar cartilage through the use of an auricular cartilage graft, with minimal deformity secondary to the donor site. The objective of the present study is to present a modification, by Collares et al., of the technique described above, which allows the reconstruction of another anatomical region of the nose without increasing morbidity, and its insertion into the total nasal reconstruction protocol of Hospital de Clínicas of Porto Alegre. Methods: A retrospective study was conducted. We evaluated technique modification in 10 patients who underwent total nasal reconstructions. Results: After examining the 10 patients who were treated with the modified total nasal reconstruction protocol at the Hospital de Clínicas of Porto Alegre, we observed an improvement in the nose shape and internal nasal valve with preservation of function, without sequelae secondary to auricular graft removal. Conclusion: In this case series, the modification of the Max Pereira technique resulted in adequate aestheticfunctional treatment when implemented in the total nasal reconstruction protocol of the Hospital de Clínicas of Porto Alegre, without increasing the morbidity in the donor area.

Manejo de la punta nasal mediante la técnica los domos inteligentes / Handling the nasal tip through the smart domes technique

"El propósito de este artículo es describir paso a paso mi técnica personal al trabajar la punta nasal en cualquier tipo de rinoplastia, técnica que he llamado "LOS DOMOS INTELIGENTES". Considero es una versátil poderosa herramienta a la hora de resolver los detalles más importante relativos a rotación, proyección, definición y soporte de la punta nasal. El manejo de esta técnica por medio de rinoplastia abierta, nos permite trabajar en forma cómoda, todas las subregiones de la punta nasal, y corregir la gran mayoría de deformidades y patologías asociadas a las narices que se operan en nuestro medio, tales como columela colgante, nariz sobreproyectada, punta ptósica, nariz con poca definición de punta, etc. Este artículo será de mucha utilidad para los colegas otorrinolaringólogos y cirujanos plásticos interesados en el tema, pues se trata de una técnica de fácil reproducibilidad y los resultados que se obtienen son bastante satisfactorios y constantes con el pasar del tiempo."

The purpose of this article is to describe step by step my own technique to work nasal tip in any type of rhinoplasty, technique I have called "THE SMART DOMES". I think is a versatile and powerful tool to solve the most important details of rotation, projection, definition and support of the nasal tip. This technique through open rhinoplasty, allows to work comfortably all sub-regions of the nasal tip, and correct the most deformities and pathologies associated with noses that are operated in our environment, such as hanging columella, overprojected nose, ptotic tip, nose tip with little definition, etc. This article will be very useful for ENT and plastic surgeons interested in the subject, as it is an easily reproducible technique and the results obtained are quite satisfactory and consistent through time.

Triangular Resection of the Upper Lateral Cartilage for Middle Vault Deviation

OBJECTIVES: Middle vault deviation has a significant effect on the aesthetic and functional aspects of the nose, and its management continues to be a challenge. Spreader graft and its modification techniques have been focused, but there has been scarce consideration for removing surplus portion and balancing the upper lateral cartilage (ULC). This study aimed to report the newly invented triangular-shaped resection technique (“triangular resection”) of the ULC and to evaluate its efficacy for correcting middle vault deviation. METHODS: A retrospective study included 17 consecutive patients who presented with middle vault deviation and underwent septorhinoplasty by using triangular resection at a tertiary academic hospital from February 2014 and March 2016. Their outcomes were evaluated pre- and postoperatively including medical photographs, acoustic rhinometry and subjective nasal obstruction using a 7-point Likert scale. RESULTS: The immediate outcomes were evaluated around 1 month after surgery, and long-term outcomes were available in 12 patients; the mean follow-up period was 9.1 months. Nasal tip deviation angle was reduced from 5.66° to 2.37° immediately (P < 0.001). Middle vault deviation also improved from 169.50° to 177.24° (P < 0.001). Long-term results were 2.49° (P=0.015) for nasal tip deviation and 178.68° (P=0.002) for middle vault deviation. The aesthetic outcome involved a complete correction in eight patients (47.1%), a minimally visible deviation in seven patients (41.2%) and a remaining residual deviation in two patients (11.8%). Pre- and postoperative minimal cross-sectional areas (summation of the right and left sides) were 0.86 and 1.07, respectively (P=0.021). Fifteen patients answered about their nasal obstruction symptoms and the median symptom score had alleviated from 6.0 to 3.0 (P=0.004). CONCLUSION: Triangular resection of the ULC is a simple and effective method for correcting middle vault deviation and balancing the ULCs without complications as internal nasal valve narrowing.

Correction of deviated nose

Deviated nose deformities have always been a surgical challenge, and it is essential to achieve both functional and esthetic improvements. Various techniques have evolved over time to correct deviated noses but no one method applies in all cases. Successful correction requires a complete understanding of the various surgical techniques and concepts, including the three-dimensional nasal structure and the time-related changes to surgically-treated noses.

Discussion on the micro-plastic operative treatment of nasal-septum deviation combined with crooked nose / 临床耳鼻咽喉头颈外科杂志

OBJECTIVES@#To explore the micro-plastic operative treatment of deviated nose combined with nasal septum deviation.@*METHODS@#We designed the incision at the caudal side of the nasal septum. The three-line reduction method for correcting nasal septum deviation was performed. The connection of the caudal nasal septum and the anterior nasal spine was reposited. The micro-plastic surgery with fixed suture was used to correct the deviated nose.@*RESULTS@#After the surgery, the nasal septum deviation was corrected, whose nasal function and symptoms improved without nasal adhesion, nasal septum perforation or other complications. Meanwhile, the nasal tips were in the middle place and nasal dorsums were straight. The aesthetic outcome was satisfactory.@*CONCLUSIONS@#Compared to the traditional orthopedic technique, the micro-shaping technique can be used for the homochromous operation of crooked nose combined with nasal septum deviation with less injury and lower risk. We suggest this micro-shaping technique be used in a rational way.

Correção do dorso nasal baixo ou em sela com enxerto composto de cartilagem conchal fragmentada fixa ao pericôndrio envolvidos à fáscia da mastóide / Correction of low or saddle nasal dorsum with a composite graft of fragmented conchal cartilage fixed to the perichondrium wrapped in mastoid fascia

Introdução: A rinoplastia de aumento em muitos casos torna-se mais difícil que a rinoplastia de redução. Enxertos dorsais sólidos realizados com cartilagem costal têm sido muito utilizados para aumento dorsal, porém estão associados com altos índices de revisão, por isso, muitos autores passaram a utilizar cartilagem em cubos envoltos por fáscia. A fáscia da mastoide, conectada ao pericôndrio da cartilagem conchal auricular, pode formar um enxerto composto para o aumento do dorso nasal, sendo também uma opção de tratamento. O objetivo é demonstrar a possibilidade do uso de cartilagem da concha auricular fragmentada fixa ao seu pericôndrio, e envoltos na fáscia da mastoide, formando um enxerto composto para aumento do dorso nasal. Métodos: Tratase de um estudo retrospectivo de 9 pacientes operados entre 2012 e 2016 no Hospital de Base da Faculdade de Medicina de São José do Rio Preto, em que foi realizado aumento do dorso nasal com cartilagem conchal fragmentada fixa ao seu pericôndrio e envolto à fáscia da mastoide. Resultados: Os pacientes foram acompanhados de 6 a 48 meses. Foram questionados quanto à satisfação do procedimento nasal e sensibilidade auricular, com avaliação positiva dos pacientes e cirurgiões. Conclusão: A cartilagem conchal parece ser uma alternativa de grande valia para procedimentos de aumento de dorso nasal. Esta cartilagem envolta com fáscia da mastoide parece ser uma alternativa vantajosa em comparação ao uso de outras fáscias, com baixa morbidade e taxa de complicações, podendo ser uma grande opção para tratamento do nariz em sela.

Introduction: In many cases, augmentation rhinoplasty is more difficult than reduction rhinoplasty. Solid dorsal grafts performed with costal cartilage have been widely used for dorsal augmentation; however, they are associated with high rates of revision. Thus, many authors began to use cartilage cut into cubes wrapped in fascia. The mastoid fascia, connected to the perichondrium of the auricular conchal cartilage can form a composite graft to augment the nasal dorsum, which is also a treatment option. The objective is to demonstrate the possibility of using fragmented auricular conchal cartilage fixed to its perichondrium and wrapped in mastoid fascia to form a composite graft for augmentation of the nasal dorsum. Methods: This is a retrospective study of 9 patients who underwent operation between 2012 and 2016 at the Base Hospital of the Faculty of Medicine of São José do Rio Preto, in which the nasal dorsum was augmented with fragmented conchal cartilage fixed to its perichondrium and wrapped in the mastoid fascia. Results: The patients were followed up for up 6 to 48 months. They were questioned about their satisfaction with the nasal procedure and hearing sensitivity, and provided a positive evaluation of the surgeons. Conclusion: The conchal cartilage seems a highly valuable alternative graft for nasal dorsum augmentation procedures. The technique of using cartilage wrapped in mastoid fascia seems to be an advantageous alternative when compared with those using cartilage wrapped in other fasciae: it has low morbidity and complications rates and can be a great option for saddle nose treatment.

Reconstrucción nasal con colgajos locales: Manejo según unidades estéticas / Nasal reconstruction with local flaps: Management according to aesthetic units

Introducción: Las lesiones neoplásicas de la nariz necesitan una resolución con resultado estético satisfactorio. El objetivo del presente estudio es realizar una descripción del lugar en donde se ubicaron las lesiones y los tipos de colgajos más utilizados. Métodos: El presente estudio descriptivo fue realizado en pacientes intervenidos en el 2013 por reconstrucción nasal secundaria exéresis tumoral en Solca-Guayaquil. Se describe la localización de la lesión y la técnica. La muestra fue incidental. Para la descripción se dividió la nariz en 3 zonas: proximal (Z1), media (Z2) y distal (Z3). Las lesiones con >1 zona fueron "defectos complejos". Las Z1 y Z2 fueron divididas en subunidades (SU) central y lateral. La Z3 fue dividida en SU: alar, domo alar, de domo, centr al, columelar y de base nasal. Los defectos con >1 SU fueron combinados. Resultados: Ingresaron al estudio 96 casos, 60 mujeres. 14 defectos (14.6 %) en Z1, 16 defectos (16.7%) en Z2, 50 casos (52 %) en Z3 y 16 defectos complejos (16.7 %). El colgajo frontal (CF) 21 casos (21.88 %), el colgajo avance V-Y (AV-Y) 19 casos (19.79 %) y el colgajo nasolabial (CNL) 15 casos (15.63 %). En Z1, la SU- central se utilizaron los colgajos glabelar (CG), AV-Y y colgajo en Mitra (CM); en la SU- lateral se utilizaron el CG y AV-Y con más frecuencia. En la Z2, la SU- central se utilizaron los CM y el cierre directo (CD); en la SU- lateral se utilizaron el CD, CM, AV-Y y CNL. En la Z3 se utilizaron CNL, AV-Y y colgajos bilobulados. El colgajo frontal fue usado en los defectos complejos y combinados. Conclusión: La SU-Alar y la SU del Surco Domal Alar de la Z3, fueron las áreas más prevalentes. Las técnicas quirúrgicas más utilizadas fueron, el colgajo frontal, el AV-Y y el CNL.

Introduction: The neoplastic lesions of the nose need a resolution with a satisfactory aesthetic result. The aim of the present study is to make a description of the place where the injuries were located and the types of flaps most used. Methods: The present descriptive study was performed in patients who underwent surgery in 2013 for secondary nasal reconstruction of tumor exeresis in Solca-Guayaquil. The location of the lesion and the technique are described. The sample was incidental. For the description, the nose was divided into 3 zones: proximal (Z1), middle (Z2) and distal (Z3). Injuries with> 1 zone were "complex defects". The Z1 and Z2 were divided into central and lateral subunits (SU). The Z3 was divided into SU: alar, domo-alar, dome, central, columelar and nasal base. Defects with> 1 SU were combined. Results: 96 cases, 60 women, entered the study. 14 defects (14.6%) in Z1, 16 defects (16.7%) in Z2, 50 cases (52%) in Z3 and 16 complex defects (16.7%). The frontal flap (FF) 21 cases (21.88%), the flap advance V-Y (AV-Y) 19 cases (19.79%) and the nasolabial flap (NLF) 15 cases (15.63%). In Z1, the SU-central glabellar flap (GF), AV-Y and Mitra flap (MF) were used; in the SU-lateral the GF and AV-Y were used more frequently. In the Z2, the central SU were used the MF and the direct closure (DC); in the SU-lateral DC, MF, AV-Y and NLF were used. In Z3, NLF, AV-Y and bi-lobed flaps were used. The frontal flap was used in complex and combined defects. Conclusion: The SU-Alar and the SU of the Domal Alar Groove of the Z3, were the most prevalent areas. The most used surgical techniques were, the frontal flap, the AV-Y and the NLF.

An often neglected area in crooked nose: middle turbinate pneumatization / Uma área frequentemente negligenciada no nariz torto: pneumatização da concha média

Abstract Introduction: Crooked or deviated nose is a deviation of the nose from the straight vertical position of the face. Extensive pneumatization of the middle turbinate, also called concha bullosa or bullous middle turbinate (BMT) is known to be one of the possible etiologic factors in nasal obstruction, recurrent sinusitis, and headache. There is no study concerning a link between BMT and crooked nose. Objective: To investigate the association between crooked nose and the presence of a BMT. Methods: A total of 199 patients who underwent open septorhinoplasty were retrospectively analyzed. Preoperative paranasal Computerized Tomography (CT) findings, preoperative photodocumentation, and anterior rhinoscopic examination findings were documented. Of the 199 patients, 169 were found to meet the criteria and were included in the study. CT scans were examined to note the presence of BMT, inferior turbinate hypertrophy, and septum deviation (SD). SDs and crooked noses were classified. Results: Ninety-four of 169 patients (56%) presented a crooked nose deformity and seventy-five of 169 patients (44%) presented a straight nose. While 49 (52%) crooked nose patients had a bulbous and extensive BMT, 20 patients with straight nose (26.6%) had a BMT. A statistically significant relationship was found between the presence of crooked nose and BMT, regardless of the side of the disease (p = 0.011). Conclusion: This study revealed a link between crooked nose and BMT.

Resumo Introdução: O nariz torto ou o nariz com desvio é um nariz com um desvio da posição vertical reta da face. A pneumatização extensa da concha média, também chamada de concha bolhosa ou concha média bolhosa (CMB), é conhecida por ser um dos possíveis fatores etiológicos da obstrução nasal, sinusite recorrente e cefaleia. Não há estudo relativo a uma associação entre CMB e nariz torto. Objetivo: Investigar a associação entre o nariz torto e a presença de CMB. Método: Foram analisados retrospectivamente 199 pacientes que se submeteram a septorrinoplastia aberta. Achados pré-operatórios paranasais à tomografia computadorizada (TC), fotodocumentação pré-operatória e exame rinoscópico anterior foram registrados. Dos 199 pacientes, observou-se que 169 atendiam aos critérios e foram incluídos no estudo. As TC foram examinadas para observar a presença de CMB, hipertrofia de conchas inferiores e desvio de septo (DS). Os DS e narizes tortos foram então classificados. Resultados: Dos 169 pacientes, 94 (56%) apresentavam uma deformidade de nariz e 75 (44%) apresentavam nariz reto. Enquanto 49 (52%) pacientes com nariz torto tinham CMB extensa, 20 pacientes com nariz reto (26,6%) tinham CMB. Uma relação estatisticamente significativa foi encontrada entre a presença de nariz torto e CMB, independentemente do lado da doença (p = 0,011). Conclusão: Este estudo revelou uma relação entre o nariz torto e CMB.

Difficult septal deviation cases: open or closed technique? / Difficult septal deviation cases: open or closed technique?

Abstract Introduction: The aim of this study is to compare the functional aspects of open technique (OTS) and endonasal septoplasty (ENS) in "difficult septal deviation cases". Methods: 60 patients with severe nasal obstruction from S-shaped deformities, multiple deformities, high deviations etc. were included in the study. The OTS was used in 30 patients and the ENS was performed in 30 patients. The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered preoperatively and at first month following surgery. Patients were also evaluated for pain postoperatively with Visual Analog Scale (VAS). Results: The mean NOSE score was decreased 62.5-11.0 in the OTS group and 61.3-21.33 in the ENS group. Improvement of the symptoms following the two surgical techniques is similar and no statistically significant difference was found between both techniques. Also there was no statistically significant difference in postoperative pain between the OTS and ENS groups evaluated by VAS. Conclusion: ENS is as successful as the OTS in management difficult septal deviation cases. In patients with severe septal deformities type of the surgical technique should be selected according to the surgeon's experience and the patient's preference.

Resumo Introdução: O objetivo deste estudo é comparar os aspectos funcionais da septoplastia entre a técnica aberta (STA) e a endonasal (SEN) em "casos difíceis de desvio de septo nasal". Método: Foram incluídos 60 pacientes com obstrução nasal devido a deformidades em forma de S, múltiplas deformidades, desvios altos, etc. A STA foi usada em 30 pacientes e a SEN em 30. A escala de avaliação do sintoma de obstrução nasal (NOSE) foi administrada no pré-operatório e no primeiro mês após a cirurgia. Os pacientes também foram avaliados com Escala Visual Analógica (EVA) para dor no pós-operatório. Resultados: O escore médio de NOSE foi reduzido de 62,5-11,0 no grupo da STA e de 61,3-21,33 no grupo da SEN. Houve melhora dos sintomas com as duas técnicas cirúrgicas e não foi encontrada diferença estatisticamente significativa entre elas. Também não houve diferença estatisticamente significativa nos graus de dor no pós-operatório que tenha sido avaliada pela EVA entre o grupo de STA e o de SEN. Conclusão: De acordo com nossos dados, a SEN é tão bem-sucedida quanto a STA no tratamento de casos difíceis de desvio de septo nasal. Em pacientes com deformidades septais graves, o tipo de técnica cirúrgica deve ser escolhido de acordo com a experiência do cirurgião e a preferência do paciente.

Rehabilitación protésica de un paciente con defecto nasal / Prosthetics rehabilitation of a patient with nasal defect

Se describe el caso clínico de un paciente de 84 años de edad, a quien se le realizó exéresis total del órgano nasal desde hacía 5 años aproximadamente en el Hospital Oncológico Conrado Benítez de Santiago de Cuba, a causa de un carcinoma epidermoide del apéndice nasal, por lo cual fue remitido al Centro de Rehabilitación Protésica Bucomaxilofacial de esta provincia para ser rehabilitado. Al examen físico extrabucal se observó ausencia total de la nariz, que simulaba una facies leonina, con bordes cicatrizados y bien definidos. La mayor preocupación del paciente era ocultar su defecto, de manera que se le realizó una prótesis nasal de silicona para mejorar su estética y funcionalidad

The case report of an 84 years patient is described, to whom a total removal of the nasal organ was carried out about 5 years ago-at Conrado Benítez Cancer Hospital in Santiago de Cuba - due to an epidermoid carcinoma of the nasal appendix, reason why he was referred to the Oralmaxillofacial Prosthetics Rehabilitation Center of this province to be rehabilitated. A total absence of the nose was observed in the extraoral physical examination that simulated a leonine facies, with well defined healed borders. The patient's biggest concern was to hide his defect, so a nasal silicone prosthesis was placed to improve his aesthetics and functionality

Rinofima: opção cirúrgica como tratamento / Rhinophyma: a surgical treatment option

Introdução: Rinofima é uma inflamação crônica dos tecidos do nariz, caracterizada por hipertrofia e hiperplasia progressivas das glândulas sebáceas e do tecido conjuntivo. Determina um aspecto de elefantíase nasal, secundária à congestão dos vasos da derme. Sua etiologia está associada, na maioria dos casos, ao uso abusivo de álcool. É considerada por alguns autores como sendo um estágio avançado de acne rosácea. O artigo tem como objetivo relatar um caso de rinofima, tratado cirurgicamente no Serviço de Cirurgia Plástica do Hospital Universitário da Universidade Federal de Santa Catarina com decorticação e eletrocoagulação. Método: Foi realizado revisão de prontuário e registro fotográfico de um caso de rinofima. Resultados: Paciente foi submetido a tratamento cirúrgico com evolução favorável. Conclusão: Existem diversos tratamentos para rinofima, sendo que a decorticação e a eletrocoagulação constituem uma excelente opção terapêutica.

Introduction: Rhinophyma is a condition involving chronic inflammation of the nose and is characterized by progressive hypertrophy and hyperplasia of sebaceous glands and connective tissue. Rhinophyma leads to an appearance of nasal elephantiasis, which is caused by the congestion of dermis vessels. Its etiology is mostly associated with alcohol abuse. Rhinophyma is considered by some researchers to be an advanced stage of acne rosacea. Here, we report a case of rhinophyma that was surgically treated with decortication and electrocoagulation at the Plastic Surgery Service of the University Hospital of the Federal University of Santa Catarina. Methods: A review of medical and photographic records of a case of rhinophyma was conducted. Results: The patient was underwent surgical treatment with favorable outcomes. Conclusion: There are several treatments for rhinophyma, with decortication and electrocoagulation being an excellent therapeutic option.