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SURGICAL MANAGEMENT OF CRS
Table 36.1 CLOSE mnemonic is widely used to facilitate systematic
preoperative interpretation of the CT images
Mnemonic Evaluated anatomical structures
C Cribriform niche: depth and asymmetry should be evaluated
L Lamina papyracea: examined for dehiscence
O (Onodi) sphenoethmoidal cells
S Sphenoid sinus: examined for dehiscence of bone overlying the
optic nerve and carotid artery
E Ethmoidal arteries: the position of the anterior and posterior
Cocaine and adrenaline, ± sodium bicarbonate (‘Moat’s solution’), soaked on neuro-
•
patties are used for topical decongestion.
Lignocaine 5% and phenylephrine 0.5% (co-phenylcaine) or oxymetazoline can be used
•
if cocaine is not available.
Inltration (2.2 mL 1% lignocaine with 1:80,000 adrenaline) of the middle turbinate,
•
nasal septum and frontal process of the maxilla (optional).
Allow time for topical and injected vasoconstrictors to establish their local eect,
•
whilst allowing their systemic eect to dissipate.
Fess for Rhinosinusitis
General Principles
Recent sinus computed tomography (CT) scans are mandatory and need to be available to
the surgeon throughout the operation (Table 36.1).
Surgical Techniques
Uncinectomy
e use of a sickle knife on the inferior portion of the uncinate is to be discouraged as
orbital penetration can easily occur. Back-biting forceps allow for safer uncinate incision
(Figure 36.1).
e uncinate process can be removed using angled through-biting forceps or can be dislocated forward using a double right-angled ball probe and cautiously removed with the microdebrider or through-biting forceps. e bone of the horizontal portion can be dissected free
from the mucosa and the natural ostium stretched open with an angled probe or sucker,
without removing any mucosa. For more advanced disease (or in revision cases), it may be
necessary to create a large middle meatal antrostomy.
Figure 36.1 A paediatric back-biting forceps is used to perform the inferior uncinectomy incision.
188 Rhinology and Facial Plastic Surgery
SURGICAL MANAGEMENT OF CRS
Figure 36.2 A double right-angle ball probe is inserted into the natural ostium of the bulla eth-
moidalis (medial) and then the anterior face is fractured anteriorly.
Removal of the Ethmoidal Bulla
e anterior face of the bulla can be fractured forwards (Figure 36.2) then removed with a
microdebrider. Other anterior ethmoidal cells can be removed in a similar manner. e use
of through-biting instruments is preferred to minimise the risk of exposing bone.
Posterior Ethmoidectomy
e ground lamella of the middle turbinate should be perforated in its inferomedial quadrant. e roof of the maxillary sinus can be used as a guide to the superior limit of dissection
within the posterior ethmoid. e optic nerve may traverse through an Onodi cell.
Sphenoidotomy
e natural sphenoid ostium is located medial to the superior turbinate at the height of the
antral roof. Part of the middle turbinate can be resected with a back-biting forceps, entering the superior meatus. e inferior third of the superior turbinate can then be resected to
access the sphenoethmoidal recess. As an alternative, an articial opening into the sphenoid
can be made through the posterior ethmoid and then extended medially to incorporate the
natural sphenoid ostium.
Frontal Sinus Surgery
Using a Kerrison’s punch in the axilla of the middle turbinate (Figure 36.3), the anterior portion of the agger nasi can be removed.
Figure 36.3 A 2-mm 450 forward-angled Kerrison’s punch is used to raise the axilla of the
middle turbinate and improve access to the agger nasi and the frontal recess.
Rhinology and Facial Plastic Surgery 189
SURGICAL MANAGEMENT OF CRS
Curettes and angled instruments can then be used to remove the posterior wall and roof of
the agger nasi to expose the frontal recess. Axillary mucosal aps are not required as adhesions can easily be prevented using other methods. Once the agger nasi has been removed,
any remaining frontoethmoidal cells can be removed, aer identication of the anterior
ethmoidal artery. Advanced frontal instrumentation such as a girae forceps or 3.5-mm
Hosemann punch may greatly facilitate surgery in this area.
Post-Operative Management
In severe disease (and most of chronic rhinosinusitis with poly ps [CRSwNP]), a 10-day
•
course of 25mg of oral prednisolone can be given without tapering.
In extensive eosinophilic disease, a 3-week course of steroids (or longer) may be
•
required (with tapering to avoid an Addisonian crisis).
ere is no evidence that prophylactic antibiotics improve outcomes.
•
Routine nasal steroids; it is important to emphasise to patients with severe disease that
•
they may need to be on topical steroid sprays or irrigations for some time (and in some
cases of eosinophilic chronic rhinosinusitis (CRS), for an indenite period) to prevent
disease recurrence.
Initially large-volume saline irrigations are used to clean the nose of mucopus, blood
•
clot and other tissue.
Following rst review at 7–10 days, less frequent irrigations can be continued until
•
review at 6 weeks or 3 months.
Surgical Complications
Analysis of the literature reveals a range of signicant complications between 0.3 and 22.4%
(median 7.0%). Excessive bleeding and poor visualisation are associated with an increase in
complication rates. High-level evidence has demonstrated that intraoperative image guidance signicantly reduces the incidence of complications.
Avoiding Complications
Anti-coagulation drugs, non-steroidal anti-inammator y drugs (NSAIDS) and homeopathic
preparations (e.g. sh oil and multivitamins) that can aect bleeding should be stopped preoperatively. e CT scans will identify dehiscence of the lamina papyracea, angulation of the
vertical lamella of the cribriform plate and congenital defects in the skull base and over the
carotid artery, which all carry higher risk.
Orbital Injury
e orbit can be damaged with the rst incision of a sickle knife through the inferior portion
of the uncinate process or when performing a middle meatal antrostomy with a long thin
infundibulum. If just orbital fat is exposed, no repair of the defect is usually necessary and
the eye should be routinely checked to identify any intra-orbital haemorrhage. Any proptosis
should be regarded as signicant and decompression of the orbit by removing the lamina
papyracea and incising the orbital periosteum may be required, with or without a lateral
canthotomy and/or cantholysis. If damage to the ocular muscles is suspected (increased with
microdebrider injury), an ophthalmological opinion should be obtained, although there is
usually little that can be done to repair a transected muscle and late oculoplastic surgery may
never restore normal movement to the damaged eye.
Optic Nerve Injury
e optic nerve can be damaged due to intra-orbital haematoma or direct injury. It is most
at risk if the optic nerve is on a mesentery within an Onodi cell. If injury to the optic nerve
190 Rhinology and Facial Plastic Surgery
SURGICAL MANAGEMENT OF CRS
is suspected, steroids should be given and an urgent ophthalmological consultation should
be obtained.
CSF Leak
e estimated prevalence of intra-operative cerebrospinal uid (CSF) leak is 0.5% of cases,
usually at the vertical lamella of the cribriform plate. Oen a CSF leak can be identied
immediately and repaired using fat plugs, articial materials or homogras with or without
covering mucosal gras and brin glue.
Carotid Artery Injury
Pre-operative CT identication of carotid dehiscence will reduce risk. A carotid injury can
be extremely dicult to manage due to the high volume of blood, which will obscure the
operative eld. e sphenoid needs to be packed and the anaesthetist must commence immediate haemostatic resuscitation. Although direct carotid artery repair (with either a J-suture
or muscle pack) has been advocated, placement of an endovascular stent is an eective alternate treatment option.
Outcomes
e limited randomised controlled trial (RCT) evidence does demonstrate more benet for
patients with CRSwNP than CRS without nasal polyps (CRSsNP). Other non-RCT data provide more support for surgery. e Royal College of Surgeons of England (RCSEng) comparative audit also found that patients with CRSwNP did better following surgery than patients
with CRSsNP. Total revision rates were 3.6%, 11.8% and 19% at 1, 3 and 5 years, respectively.
Balloon Sinuplasty
Balloon dilatation of either the maxillary, frontal and/or the sphenoid sinus ostia is an alternative technique that is increasingly being performed. It is expensive and highly controversial, but there is evidence that balloon dilatation can maintain 91.6% patency of the sinus
ostia at 2 years. Small RCTs have shown balloon dilatation to be non-inferior to FESS and a
non-RCT has shown balloon dilatation to produce lower sinonasal outcome test (SNOT-20)
scores compared with conventional FESS at 3 months.
Rhinosinusitis in Children
Adenoidectomy alone is recommended as a rst-line treatment of acute rhinosinusitis (ARS;
50–80% improvement), reserving endoscopic sinus surgery for rare and resistant cases. In
CRS, there may be a role for surgery in patients with cystic brosis and immune deciencies
to provide better access for topical irrigations and medications.
KEY POINTS
• FESS is an effective technique for patients with both CRSwNP and CRSsNP when
medical management has failed.
• Revision rates for FESS are generally between 10 and 20% over a 5-year period, more
so in patients with CRSwNP.
• Good pre-operative planning, surgical technique and post-operative follow-up have
been demonstrated to produce optimal outcomes.
• FESS has been demonstrated to improve the effective medical management of patients
with eosinophilic CRS.
• CRS remains a mucosal disease, and ongoing medical management is typically
required to prevent recurrent symptoms despite adequate FESS.
Rhinology and Facial Plastic Surgery 191
COMPLICATIONS OF RHINOSINUSITIS
37. COMPLICATIONS OF RHINOSINUSITIS
Complications of rhinosinusitis result from progression of infection beyond the sinuses,
causing signicant morbidity from local or distant spread. Complications are more accentuated in children and adolescents because of their thinner, more porous bony septa and sinus
walls, open suture lines and larger vascular foramina.
Classication
Complications may be caused by either local progression or distant spread via the bloodstream (Table 37.1). Local progression is typically through areas where the surrounding bone
is thin such as the porous lamina papyracea, where there is a direct anatomical connection
or through osteitic bone. Direct routes of spread occur through neurovascular foramina such
as the infra-orbital canal, or via the valveless diploic veins of Breschet. e venous drainage
of the sinus mucosa is via these diploic veins, which communicate with the dural venous
plexus. Local complications can be specic for the individual sinus groups and may be discussed relating to their presumed anatomical sinus of origin.
Frontal
Anterior spread of f ronta l sinusitis may cause a subperiosteal abscess and osteomyelitis (Pott ’s
puy tumour [PPT]). Posterior spread of infection can cause intra-cranial complications.
Ethmoid
Orbital cellulitis is the most frequent complication of ethmoid sinusitis.
Maxillary
Isolated maxillary rhinosinusitis rarely gives rise to acute complications. Acute cheek swelling usually results from dental disease, though there may be an associated secondary maxillary rhinosinusitis.
Sphenoid
Isolated sphenoid sinusitis is rare, but complications can result in meningitis or cavernous
sinus thrombosis. In cavernous sinus thrombosis infection may spread through veins from
the paranasal sinuses and orbit to the cavernous sinuses as thrombophlebitis or by septic
emboli.
Table 37.1 Complications of rhinosinusitis (gures in brackets indicate relative frequency)
Orbital (60%) Intracranial (15–20%) Bony (5–10%) Chronic
Preseptal cellulitis (50%) Subdural empyema
(38%)
Postseptal cellulitis or orbital
cellulitis without abscess
(35%)
Subperiosteal abscess (15%) Extradural abscess
Orbital abscess (<1%) Meningitis (2%)
Cavernous sinus thrombosis*Cavernous* or superior
*
Cavernous sinus thrombosis is classied as an intracranial complication but is also often included
among orbital complications due to its relation to the orbit.
192 Rhinology and Facial Plastic Surgery
Intra-cranial abscess
(30%)
(23%)
sagittal sinus
thrombosis (2%)
Osteomyelitis and
Pott’s puffy tumour
Mucocoele
and pyocoele
COMPLICATIONS OF RHINOSINUSITIS
Clinical Presentation
Any of the complications described above may present with symptoms or signs of rhinosinusitis. e rhinosinusitis can also be asymptomatic.
Orbital Complications
Up to 3% of sinusitis cases will progress to orbital cellulitis with 60–85% of orbital cellulitis
cases secondary to sinusitis. e remainder of cases are caused by processes such as dacryocystitis or facial infection.
Fi g u re 37.1 illustrates the management algorithm. Onset is noted by swelling around the
eye. Oedema results from congestion of veins draining the eyelid and can be present when
the infection is still conned to the sinus. Orbital cellulitis is far more common in children
and young adults. Visual problems are a late sign. Initially signs may be unilateral, bilateral
disease propagates via the intercavernous sinuses. According to Chandler’s classication,
orbital complications may be divided into ve stages based on their clinical and radiological
ndings (Table 37.2).
Investigations
Examination
Nasendoscopy
•
Eye assessment for chemosis, eye movements, proptosis, relative aerent pupillary
•
defect, visual acuity (Snellen chart), colour vision (Ishihara plates) and fundoscopy
Neurological examination for signs of intra-cranial complications (cavernous sinus
•
thrombosis): progressive ophthalmoplegia, visual impairment, headaches and trigeminal paraesthesia
A neurological examination for intracranial complications
•
e aim of these investigations is to:
Conrm diagnosis
•
Dene the extent and site
•
Plan treatment including surgical approach
•
Identify covert complications
•
Monitor response to treatment
•
Contrast-enhanced computed tomography (CT) is advised rst-line imaging. As CT scanning can miss up to 50% of intra-cranial complications, magnetic resonance imaging (MRI)
is advised for suspected intracranial complications.
Other Investigations
Blood cultures
•
Sinonasal/abscess pus culture, ideally from initial nasal endoscopy
•
Treatment
Most patients with complications require admission. Non-surgical management of rhinosinusitis complications is oen rst choice unless abscess formation is demonstrated. e
exception is when vision is aected by pressure on the optic nerve from inammation without abscess.
Antibiotics form the mainstay of medical treatment. Expert opinion suggests decongestants aid resolution by reducing mucosal oedema, though evidence is inconclusive. Selection
of antibiotics is empirical (broad spectrum) followed by culture-specic sensitivities.
Polymicrobial and anaerobic isolates are more common in patients over 15 and with intracranial complications.
Evidence of an abscess on the CT scan or lack of clinical improvement aer 24–48 hours of
intravenous (IV) antibiotics are indications for orbital exploration and drainage.
Rhinology and Facial Plastic Surgery 193
comPlicAtions of rhinosinusitis
Orbital cellulitis management guideline – For Adults & Paediatrics
Is it limited to Preseptal Cellulitis?
• i.e. Eyelid only & eye not involved
• Oral Co-amoxiclav
(clindamycin if penicillin allergic)
• Consider treating as an outpatient with
review in eye casualty in 24-48 hours
No
Indication for admission – any of:
• Clinical suspicion of post-septal cellulitis
• Pyrexia
• Immunocompromised
• Had 36-48 hours of oral antibiotics
• <12 months old
• Unable to assess eve due to swelling
Medical management
• ADULTS – iv Tazocin (allergy; lv clindamycin & iv ciprofloxacin)
• PAEDS – iv co-amoxiclav (allergy; iv cefuroxime &
metronidazole if mild allergy – other allergy discuss with micro)
• IMMUNOCOMPROMISED – discuss all with microbiology/ID
• Consider nasal Otrivine & nasal steroids
• 4 hourly eye & neuro-observations
• Urgent Ophthalmology assessment & daily review
• Urgent Otolaryngology assessment & daily review
Indication for imaging
• CNS involvement
• Unable to examine eye/open eyelids
• Eye signs – any of: proptosis, restriction/pain
on eye movement, chemosis, RAPD, reduced
visual acuity/colour vision/visual field, optic
nerve swelling
• Failure to improve or continued pyrexia after
36-48 hours IV antibiotics
Contrast enhanced CT Orbit, Sinuses and Brain
Surgical management
• Approach depends on local skill set
Evacuation of orbital pus
Drainage of paranasaI sinus pus
Discuss any intracranial complication with both neurosurgery & microbiology
Yes
No Orbital Collection
Continue medical
management,
rescan if failure to
improve after
Proptosis
Eye movt
Vision
Colour vision
RAPD
Baseline Investigations
• FBC, CRP, lactate (& blood culture if pyrexia)
• Endonasal swab
36-48 hours
PreseptalPost septal
NoYes
NormalPainful + restricted
NormalWorse in severe
NormalWorse in severe
Absent i.e normalYes in severe
Discharge
• Discharge once swelling
has resolved and
pyrexia settled with
oral antibiotics;
-co-amoxiclav
-clindamycin if
penicillin allergic
Yes
NO - Discuss
with
microbiology/ID
No
Improvement in 36-48 hours
Outpatient TreatmentOrbital Collection
Admission
Medical Management
Imaging
Surgical Management
Figure 37.1 Management algorithm for orbital complications. FBC = full blood cell count,
CRP = c-reactive protein, CNS=central nervous system, RAPD=relative afferent pupillary defect
(From Okonkwo ACO, Powell S, Carrie S, Ball SL. A review of periorbital cellulitis guidelines in
Fifty-One Acute Admitting Units in the United Kingdom. Clin Otolaryngol. 2018;43(2):718–721.)
ere have been a few studies showing good outcomes with IV antibiotics in children with
subperiosteal abscesses. In such cases, and provided there is clear clinical improvement
within 24–48 hours, no decrease in visual acuity, small size (<0.5–1 mL in volume), medially
located and no signicant systemic involvement, the decision might be to withhold surgical
drainage and closely monitor the patient.
194 Rhinology and Facial Plastic Surgery
COMPLICATIONS OF RHINOSINUSITIS
Table 37.2 Chandler classication
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Postseptal
cellulitis or
Preseptal
cellulitis
Inammation
does not
extend
beyond the
orbital
septum*
*
Medial orbital periosteal reection that is attached to the medial eyelid at the tarsal plate.
orbital cellulitis
without abscess
Inammation
extends into the
tissues of the
orbit beyond
orbital septum*
Subperiosteal
abscess
Abscess formation
deep to the
periosteum of the
orbital bones,
typically at the lamina
papyracea from
ethmoid sinusitis
Orbital
abscess
Abscess
formation
within the
orbit, which
has breached
the periosteum
Cavernous sinus
thrombosis/
abscess
Cavernous sinus
thrombosis after
posterior
extension of the
infection through
the superior
ophthalmic veins
An endoscopic approach involves an ethmoidectomy followed by opening the lamina papyracea and draining the abscess. External approaches to lateral and medial orbital abscesses
can also be used if necessary.
Cavernous Sinus Thrombosis
Prolonged broad-spectrum antibiotics must be given for at least two weeks beyond clinical resolution as bacteria sequestered within the thrombus may not be eradicated until the dural sinuses
recanalise. Surgery is indicated for non-draining sinus infection or abscess. ere remains no
consensus for anti-coagulation; proponents suggest anti-coagulants prevent thrombus propagation and are anti-inammatory. ose against hypothesise thrombus formation walls o infection and prevents spread, with anticoagulants increasing the risk of intra-cranial bleeding.
Prognosis of Orbital Complications
If prompt treatment is carried out with adequate monitoring, the prognosis for normal vision
is excellent. However, there is a small risk of diplopia following surgery.
Intracranial Complications
Brain Abscess
Estimates suggest 40–60% of brain abscesses arise from rhinosinusitis. Reported incidence
of intra-cranial complications from acute rhinosinusitis is between 3 and 17% of hospitalised
sinusitis patients.
Subdural Empyema
Subdural empyema is one of the most common intracranial complications. e brain is
more exposed as the infection is beyond the dura mater and allows thrombosis of the local
venous network. Serious neurological injury can occur if not treated rapidly and aggressively
with combined medical treatment and neurosurgical drainage to decompress the brain and
evacuate empyema. Subdural empyemas present with meningeal irritation and neurological
signs such as seizures or focal decits.
Extradural Empyema
Extradural empyemas tend to be less symptomatic as the brain is protected by the dura
mater. e signs are less marked and specic and are oen only present when the collection
reaches a size to cause mass eect.
Rhinology and Facial Plastic Surgery 195
COMPLICATIONS OF RHINOSINUSITIS
Brain Infarction
Cerebral ischaemia and infarction are rare vascular complications of sinusitis from either dural
venous thrombosis secondary to adjacent empyema, or cavernous carotid artery occlusion.
Clinical Presentation
Early symptoms are oen non-specic such as headache, fever, seizure, drowsiness, diplopia
(cranial nerve VI palsy), eye pain and nausea. ere may not be symptoms and signs of acute
rhinosinusitis. Adolescent males are most aected, which may be due to the vascularity of the
diploic system. ere may be specic neurological symptoms with a well-dened intracranial
abscess including acute pain or possible loss of consciousness associated with meningitis.
Investigations
MRI is more sensitive than CT for intracranial complications. CT is desirable to demonstrate
bony anatomy of the paranasal sinuses. Intracranial complications may be relatively silent
and a high index of suspicion should be maintained. Intracranial complications may also
develop aer the initial presentation and any change in neurological status should merit
consideration for repeat imaging.
Treatment
As soon as an intracranial complication is detected, joint management of the case with neurological or neurosurgical colleagues is mandatory. If possible, surgery to drain aected
paranasal sinuses should be undertaken synchronously with neurosurgery. e rationale is
to evacuate the intracranial collection and manage the source of infection using a rhinological approach, which will provide microbiological samples.
Prognosis from Intracranial Complications
Published mortality rates vary between 0 and 25% according to the complication, increases
with age and decreased level of consciousness on presentation. Early recognition of complications and multidisciplinary treatment is essential.
Bony Complications
Pott’s Puffy Tumour (PPT)
PPT is subperiosteal cellulitis or abscess of the frontal bone associated with frontal osteomyelitis. e reported rate of coexistent intracranial complications is high, but not all are present on initial imaging, suggesting prompt imaging and treatment are paramount.
ere is a growing body of evidence that uncomplicated PPT can be managed successfully
via an endoscopic approach/minimal external drainage, combined with long-term antibiotics. Once the acute phase has subsided the patient should be re-evaluated to determine
whether a frontal sinus drainage procedure is required for long-term management.
Associated intracranial complications necessitate prompt neurosurgical intervention. is
is typically performed through a bifrontal craniotomy enabling drainage of intracranial pus
and removal of necrotic bone. Complete removal of the posterior table will require frontal
sinus cranialisation. Extensive osteomyelitis of the anterior table may necessitate a Riedel’s
procedure with removal of the anterior wall and oor of the frontal sinus allowing the forehead skin to collapse onto the posterior table. e cosmetic deformity can be reconstructed
when all infection has resolved.
Chronic Complications
Chronic complications usually result from chronic rhinosinusitis. e nature of the complication depends on the sinus or group of sinuses involved. Mucoceles are chronic, slowly
expanding lesions in any of the sinuses that may result in bony erosion and can extend
beyond the sinus. It is unusual for chronic rhinosinusitis to cause orbital cellulitis or intracranial complications unless there is an infective exacerbation.
196 Rhinology and Facial Plastic Surgery
NASAL AIRWAY SURGERY: MANAGEMENT OF SEPTAL DEFORMITIES
Nasal bone K stone area
)
)
spine
or repostion
Bone
KEY POINTS
• The major complications of rhinosinusitis are orbital and intra-cranial infections, of
which orbital complications are more common.
• The incidence of complications is greatest in children and young adults.
• The speed of initiating treatment and conrming the diagnosis can greatly reduce the
morbidity and extent of intervention required.
• Multidisciplinary care involving ear, nose and throat (ENT) surgeons with
ophthalmology, pediatric and neurology/neurosurgical input as required is a standard
of care.
38. NASAL AIRWAY SURGERY: MANAGEMENT OF SEPTAL DEFORMITIES
Nasal Septum
e nasal septum is divided into bony, cartilaginous and membranous parts. e bony septum is mainly formed by the perpendicular plate of ethmoid and vomer. e palatine bones
and maxillary crest form the most posterior parts of the bony septum. e cartilaginous
septum (i.e. quadrilateral cartilage) is not an isolated cartilage and is in unison with the
upper lateral cartilages (ULCs). An L-shaped strut of septum (forming the dorsal and caudal
segments) measuring approximately 1 cm in width is required to support the external nasal
skeleton (Figure 38.1).
Septal examination should include inspection as well as palpation. During inspection, the
position of deviation should be mapped in relation to the L-strut. Nasendoscopy will allow
inspection of the anatomy in the neutral position; it also shows more posterior elements in
the nasal cavity (e.g. adenoidal tissue).
Nasal airow can be demonstrated by misting of the examination mirror or metal tongue
spatula. Absence or reduction of the misting indicates a structural blockage but a satisfactory
amount of misting does not indicate a patent nasal airway as perceived by the patient during
inspiration.
Dorsal ‘L’ strut
Perpendicular
plate of ethmoid
graft
Figure 38.1 Septal cartilaginous L-strut with a minimum 10-mm width is preserved for structural
support. The body of the bony and cartilaginous septum can be used as grafts.
Vomer
Resect for graft
Anterior nasal
(reshape, reposition, strengthen
Septal cartilage graft
Caudal ‘L’ strut
(reshape, reposition, strengthen
Rhinology and Facial Plastic Surgery 197
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