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Chapter Medical Management of Rhinologic Disorders in the Rhinoplasty Patient 55
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Corticosteroids
Corticosteroids, both systemic and topical, are potent antiinammatory agents
with general applications in the management of tissue inammation, whether it
is related to surgical edema, allergic phenomena, or infection.
Rhinologists have embraced the ecacy of steroids, as evidenced by the widespread acceptance of topical nasal steroids as rst-line agents in the management of allergic rhinitis and their increased use in managing chronic sinonasal
inammation.
Although the targeted forms of therapy address the mediator eects of inammation, corticosteroids exert an immunomodulatory eect to prevent initiation
and downregulate the inammatory responses. Steroids reduce the inux of inammatory cells, attenuate the availability of inammatory mediators, and reduce the development of hyperresponsiveness. Corticosteroids, by virtue of their
lipophilic nature, directly enter the target cell and bind to a steroid receptor. e
steroid-bound receptor alters mRNA transcription and ultimately protein translation to alter the expression of inammatory mediators. Corticosteroids exhibit
a profound inhibitory eect on proinammatory cytokine production such as
interleukin- (IL-), IL-, IL-R, interferon-alpha, and tumor necrosis factor. In
allergic rhinitis, the ecacy of corticosteroids in mitigating early phase reactions
and late phase reactions has been well established.
Topical Intranasal Steroids
Unlike systemic corticosteroids, which almost exclusively aect the late phase
allergic reaction, pretreatment with topical nasal corticosteroids for up to a week
has a benecial eect on both acute and late phase allergic reactions. Topical steroids decrease eosinophil recruitment and immigration in addition to increasing
apoptosis. Additionally, they attenuate the eect of basophils and mast cells by
decreasing the amount of histamine. However, it is worth emphasizing that these
compounds do not prevent the allergic reaction but simply blunt the eects of
the mediators thus released.
Topical nasal steroidal agents act locally on the nasal mucosa, and because their
antiinammatory action is nonspecic, they are useful in the treatment of both
allergic and nonallergic rhinitis.
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Eective dosing requires regular use of topical nasal steroids. Some ecacy is
achieved aer administration of a single dose, but the full benet requires regular use. e eective use of nasal steroids (as with any nasal preparation) begins
with the drug being able to penetrate the nasal cavity and come in contact with
the target mucosa. For this reason, patients with severe septal deviation and/or
signicantly hypertrophic inferior turbinates will benet to a considerably lesser
degree from the use of nasal corticosteroids in comparison to patients without
such obstruction. A systemic decongestant or a brief course of a topical decongestant may be necessary in conjunction with nasal steroids (especially at the
initiation of therapy) to ensure adequate penetration past congested areas.
With the increasing use of intranasal steroids for the treatment of allergic rhinitis and chronic disease, there has been much debate as to their safety and the
potential for local or systemic side eects. Intranasal steroids have been associated with several local side eects, including epistaxis, dryness, and burning.
Local side eects may occur with any nasal steroid preparation. In addition to
local discomfort caused by preservatives and vehicles, side eects frequently involve nasal crusting and dryness, epistaxis, headache, and sore throat. Excoriation or ulceration of the nasal septum may follow nasal steroid therapy, but the
most likely contributory factor is trauma to the septum. is can be avoided by
carefully instructing patients to direct the tip of nasal steroid sprays away from
the septum (pointing it toward the corner of the eye), thereby avoiding contact
with the septum.
Patients should be instructed to direct the tip of nasal steroid sprays away from
the septum (pointing it toward the corner of the eye), thereby avoiding trauma
to the septum and sequelae including crusting, dryness, and epistaxis.
Although there have been reports of septal perforations, several studies have
demonstrated no evidence of mucosal atrophy, mucosal metaplasia, or impairment of mucociliary function. e systemic availability of the topical steroids
is variable. Wilson et al showed that -hour mean plasma cortisol levels are
similar across all groups. Benninger et al reviewed the safety of intranasal steroids and concluded that they are not associated with systemic side eects such
as the hypothalamic-pituitary-adrenal (HPA) axis suppression, linear growth,
and local side eects.
Intranasal Corticosteroid Injection
e submucosal injection of a repository corticosteroid at the anterior tip of the
inferior turbinates results in a slow uptake of the material with spreading to the
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adjacent nasal mucosa, oering symptomatic relief of allergic rhinitis (and other
forms of rhinitis) beginning within a few hours and persisting for to weeks.
e slow absorption of the injected steroid does not generally result in suppression of endogenous cortisol production, indicating that the eect is local rather
than systemic.
A review of all published and available unpublished data on visual loss following intranasal steroid injection indicated that the mechanism involved was either retinal vasospasm or embolization of the injected material into the retinal
circulation through collateral channels from the nose to the eye. Suggestions
for preventing such complications included preparing the nasal mucosa by the
application of a topical vasoconstrictor−anesthetic solution, use of a ne needle
for injection, avoidance of steroid preparations with large particle size and high
viscosity, placement of the injection just beneath the mucosa in the anterior tip of
the inferior turbinate (as far away from retinal collateral vessels as possible), and
use of a very gentle technique during injection. Following these guidelines, one
investigator performed more than , such injections over almost years,
with no visual complications.
e results of an intraturbinal corticosteroid injection are usually noted within a
few hours of the injection, and if triamcinolone acetonide has been injected, these
eects last for to weeks. is procedure is extremely helpful for symptom relief in patients with severe nasal allergic symptoms limited to a single season. If
several injections per year are necessary, the patient is probably a candidate for
maintenance therapy with topical steroids.
Systemic Steroids
Corticosteroids are an important means of treating various types of nasal inammation, and they are oen used perioperatively for surgical treatment of AFS
and CRS. However, when administered systemically, they possess a potential for
producing signicant adverse eects. Pharmacologic doses of systemic corticosteroids may suppress endogenous cortisol production. Aer the administration
of to mg of prednisone or the equivalent for week, an additional week is
required for adrenal recovery; aer prolonged high-dose therapy, year may be
required before recovery of adrenal function.
Antibiotics
e role of antibiotics has been rmly established for the treatment of rhinosinusitis. However, their routine use in surgery remains a point of controversy. Topical and systemic antibiotics are frequently used in rhinoplasty. Topical antibiotic
ointment has been shown to signicantly decrease the growth of potentially in-
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fectious nasal ora and of Staphylococcus aureus in patients with nasal packing.
In a survey of plastic surgeons, Perrotti et al found that % of respondents used
antibiotics during or aer rhinoplasty, and there was a % increase in the use
of perioperative antibiotics in rhinoplasty between and . Despite their
widespread use and apparent ecacy, no clear guidelines exist in the literature
regarding the use of antibiotics in aesthetic surgery. Frequently cited rationales
for antibiotic prophylaxis in rhinoplasty are the use of intranasal splints and the
fear stemming from reports of toxic shock syndrome, the clean-contaminated
nature of the surgical wound, and the use of gras.
TREATMENT STRATEGIES
Because of the prevalence of allergic rhinitis and its contributory eect on other
inammatory sinonasal disease processes, adequate control of symptoms should
precede surgical intervention.
Optimizing the patient’s allergic symptoms before surgery will improve patient
satisfaction in the postoperative period.
Patients with allergic rhinitis are not a homogeneous group; therefore each patient requires individual consideration when choosing a pharmacotherapeutic
treatment regimen to maximize symptomatic relief. Combining the individual
attributes of each class of medication and matching these attributes to the individual patient will help to achieve this goal. Features that help to dierentiate
patients include quality of symptoms (irritative symptoms versus congestion),
how predictable the allergen exposure might be (for example, predictable intermittent, nonpredictable intermittent, prolonged seasonal, or prolonged perennial), and the degree of inammation (perhaps most important in the case of
prolonged exposure to an antigen). Adherence to such a strategy will decrease
the tendency to use inappropriate medications to address symptoms as well as
to decrease duplication of medications within a class.
A patient with allergic rhinitis does not typically achieve relief of all symptoms
with the use of a single medication. Antihistamines relieve the irritative symptoms (itching, sneezing, and rhinorrhea) that typify this disorder and have the
added benet of being relatively rapid in their onset of action. As a result, this
class of medications can be used to either treat prophylactically or as a “rescue”
medication to relieve symptoms aer their onset. As such, a second- or third-
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generation antihistamine may be given prophylactically or to relieve symptoms
as needed. It is important to recognize that antihistamines fail to eectively address congestion. Decongestants are necessary to relieve nasal stuness.
Nasal corticosteroids have become the mainstay of the treatment of patients with
more severe or chronic nasal allergic symptoms. In comparisons of the eectiveness of antihistamines versus nasal steroids, nasal steroids were found to be more
eective in relieving the majority of allergy symptoms. When patients have
severe and/or chronic symptoms that necessitate medication on a daily basis, it
is appropriate to switch to the use of a nasal steroid. is should then be used
daily throughout the expected season of allergen exposure, with antihistamines
and/or decongestants to be relegated to a role of augmentation as an “as needed”
medication. Further, the eectiveness of nasal corticosteroids is optimized by
use in a regular fashion over a period of time of up to several weeks. Conversely,
nasal corticosteroids, when compared with antihistamines, are a less appropriate
“rescue” choice to arrest symptoms aer their onset.
In situations in which rhinorrhea does not respond to either nasal steroids or topical ipratropium, a combination of the two may be eective. e patient should
be maintained on a nasal corticosteroid in the usual dosage, adding ipratropium
daily with the usual morning dose and supplemental doses of ipratropium once
or twice later in the day as needed. is same approach may be used in patients
whose rhinorrhea is only partially relieved with antihistamines, and who (for
whatever reason) are not candidates for nasal steroid therapy.
CONCLUSION
Rhinoplasty surgeons inevitably encounter therapeutic considerations when
managing their patients, and a thorough understanding of nasal function as well
as disorders of the nose and sinuses is requisite for positive clinical outcomes.
Rhinoplasty is not precluded in patients with allergic rhinitis, and other disease
processes may warrant an otolaryngologic evaluation before proceeding with
surgery.
A thorough medical history and examination may elucidate sinonasal disease
conditions that may not improve aer septorhinoplasty but potentially could
respond to pharmacologic therapy.
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KEY POINTS
■
A thorough understanding of nasal function and the impact of rhinologic
disease processes is crucial to the overall success of the rhinoplasty surgeon.
■
Allergic rhinitis may present as a single rhinologic disease, or it may coexist
with or contribute to other rhinologic disease processes.
■
Rhinoplasty is generally contraindicated in the presence of active infection.
■
Rhinoplasty patients who have symptomatic allergic rhinitis and who take antihistamines should continue their medication regimen in the perioperative
period.
■
e risk of rhinitis medicamentosa can be minimized by limiting topical decongestant use to just to days.
■
Topical nasal steroidal agents act locally on the nasal mucosa, and because their
antiinammatory action is nonspecic, they are useful in the treatment of both
allergic and nonallergic rhinitis.
■
Patients should be instructed to direct the tip of nasal steroid sprays away from
the septum (pointing it toward the corner of the eye), thereby avoiding trauma
to the septum and sequelae including crusting, dryness, and epistaxis.
■
Optimizing the patient’s allergic symptoms before surgery will improve patient
satisfaction in the postoperative period.
■
Rhinoplasty is not precluded in patients with allergic rhinitis, and other disease processes may warrant an otolaryngologic evaluation before proceeding
with surgery.
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9. Millman B, Smith R. e potential pitfalls of concurrent rhinoplasty and endoscopic sinus surgery.
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12. Weiler JM, Woodworth G, Watson G. Drug eects on driving performance. Ann Intern Med
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16. Kirkegaard J, Secher C, Borum P, et al. Inhibition of histamine-induced nasal symptoms by the H
antihistamine chlorpheniramine maleate: demonstration of topical eect. Br J Dis Chest :-,
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17. Mabry RL. Topical pharmacotherapy for allergic rhinitis: new agents. South Med J :-, .
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stable hypertension. Ann Intern Med :-, .
20. Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation.
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21. Krause HF. Pharmacology of upper respiratory allergy. Otolaryngol Clin North Am :-,
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22. Ferguson BJ. Cost eective pharmacotherapy for allergic rhinitis. Otolaryngol Clinic North Am
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23. Mygind N, Borum P. Anticholinergic treatment of watery rhinorrhea. Am J Rhinol :-, .
24. Bisgaard H, Olsson P, Bende M. Eect of leukotriene D on nasal mucosal blood ow, nasal airway
resistance and nasal secretion in humans. Clin Allergy :-, .
25. Okuda M,Watase T, Mezawa A, et al. e role of leukotriene D in allergic rhinitis. Ann Allergy
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26. Knapp HR. Reduced allergen-induced nasal congestion and leukotriene synthesis with an orally
active -lipoxygenase inhibitor. N Engl J Med :-, .
27. Meltzer EO, Malmstrom K, Lu S, et al. Concomitant montelukast and loratadine as treatment for
seasonal allergic rhinitis: a randomized, placebo-controlled clinical trial. J Allergy Clin Immunol
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28. Mabry RL. Intranasal corticosteroids and cromolyn. Am J Otolaryngol :-, .
29. Wawrose SF, Tami TA, Amoils CP. e role of guaifenesin in the treatment of sinonasal disease in
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tion? A description of the course of events and a discussion of the causes. Rhinology :-,
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33. Wilson AM, Sims EJ, McFarlane LC, et al. Eects of intranasal corticosteroids on adrenal, bone,
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35. Mabry RL. Evaluation of systemic absorption of intraturbinally injected triamcinolone. Otolaryn
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38. USP Drug Information for the Health Care Professional, th ed. Rockville, MD: United States
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5
Preoperative Concepts
for Rhinoplasty
Rod J. Rohrich Jamil Ahmad
T
horough preoperative preparation is a fundamental component of successful rhinoplasty and the basis for consistent and reproducible outcomes.
preoperative process includes a comprehensive nasal history, precise anatomic
examination of the external and internal nasal structures, documentation of the
patient’s deformities, establishment of the patient’s surgical goals and expectations, and reconciliation of the patient’s expectations with the dened deformity.
Careful attention to each of these details is essential for proper patient selection
and critical to achieving a successful rhinoplasty with a satised patient.
,
e
Important aids to assist the surgeon in this process include standardized photography and computer imaging systems for documentation and visual explanation
of the deformity and the operative goals for correcting it, a detailed printed information packet outlining the entire perioperative course, and preoperative and
postoperative instructions. Finally, highly trained sta who can accurately discuss
the operative process and reassure the patient along the way help to ensure that
the patient will be well informed. Useful strategies for a thorough preoperative
preparation are presented in this chapter.
Successful rhinoplasty begins with careful preoperative preparation and planning.
INITIAL CONSULTATION
e objective of the initial consultation is twofold: () to provide the surgeon with
the opportunity to compile data from the patient’s complete history and physical
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examination, which is essential before any surgical procedure, and () to develop
a rapport with the patient and establish a line of communication between the
patient and the surgeon to determine whether he or she is an appropriate candidate for rhinoplasty.
Failure to identify poor candidates with unrealistic expectations at this stage can
lead to signicant problems later on. e surgeon should not be afraid to refuse
to operate on any prospective rhinoplasty patient whom he or she considers unsuitable. Although this may be dicult initially, it will serve the surgeon well in
the long run. Above all, the surgeon should be honest and objective with these
patients about what is possible to achieve and what is not.
HISTORY
e patient’s history should establish whether he or she is medically, physically,
and emotionally prepared to undergo rhinoplasty. A complete and accurate history focuses on the aesthetic concerns (chief complaint), past medical history,
past surgical history (nasal and other), nasal and/or upper respiratory symptomatology, history of nasal trauma, review of systems, and current medications.
e patient’s chief complaint is documented in the chart. e specic reason that
brought the patient to the oce should be elicited. Patients who indicate multiple
aspects of their nasal appearance that they nd objectionable should be asked to
rank them in order of importance. It is sometimes helpful to ask the patient, “If
you had only one problem that could be corrected, what would it be?” e surgeon should not settle for vague descriptions or explanations, because that may
lead to a potential misunderstanding of the patient’s expectations. Poorly dened
objectives for surgery are a red ag to not operate on that patient. Time spent
understanding the patient’s goals will be time saved postoperatively. Patients
commonly misuse medical terminology, or they are unfamiliar with terminology used to describe anatomic structures, deformities, and surgical maneuvers
in rhinoplasty. It is important to clarify these terms with the patient and present
information in a manner that is easy for the patient to understand.
Essential elements of the nasal history include nasal airway problems, allergies,
medications, previous nasal trauma, and prior nasal surgery.
Past medical history should be reviewed in detail to identify any medical contraindications to rhinoplasty or the need for preoperative consultation and/or medical clearance for surgery. A patient’s past surgical history will help to conrm or
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