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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4450_Библиотеки_им_академика_М_И_Перельмана
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A cell in the inferior turbinate is very rare. Only a few cases
have been described.
Hyperplasia of the Turbinate Head
Hyperplasia of the turbinate head is a very common type of
pathology observed in most patients suffering from allergic
rhinitis, nasal hyperreactivity, or chronic infection.
In the inferior turbinate, the hypertrophic head protrudes
in a medial and anterior direction and may obstruct the
valve area.
In the middle turbinate, hypertrophy is often combined
with polypous degeneration of the mucosa. The middle
meatus is obstructed, and drainage and ventilation of the
paranasal sinuses may be compromised. Facial neuralgia
may result.
Hyperplasia of the Whole Turbinate
Hyperplasia of the whole turbinate is an even more
common symptom of allergic rhinitis, nasal hyperreactivity,
or chronic infection.
In the inferior turbinate, this is a very common type of
pathology that causes permanent nasal obstruction to
differing degrees, and requires treatment (▶ Fig. 2.121).
Fig. 2.121Hypertrophy of the entire inferior turbinate on the right.
The same applies to the middle turbinate. In this case, the
hypertrophy is usually a symptom of a more extensive
pathological syndrome.
Hyperplasia of the Turbinate Tail
This is frequently seen in patients with chronic sinusitis
and postnasal discharge. Due to continuous irritation and
infection, the mucosa degenerates with the formation of
polypoid, papillomatous, or fibrous new growth (▶ Fig.
2.122).
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Fig. 2.122Degenerated mucosa of the tail of the right inferior turbinate.
2.3Diagnosis and Documentation
2.3.1Making the Diagnosis
There are four basic steps to diagnosis in reconstructive
nasal surgery:
1. Recording the patient’s complaints and taking the
medical history
2. Examining the nose and related structures
3. Arranging photography and imaging and taking
measurements when required
4. Performing function tests
Completion of these diagnostic steps generally requires two
or three office visits. The findings are reviewed prior to
surgery on the day the patient is admitted to hospital. The
final diagnosis is made at surgery after topical anesthesia
and mucosal decongestion have taken effect.
The first visit is devoted to listening to the patient’s
complaints, taking a general medical and rhinological
history, and conducting an initial examination of the nose
and related structures. Arrangements for photography,
imaging (CT and/or MRI), and function tests (e.g.,
rhinomanometry, acoustic rhinometry, and olfactometry)
are made (see ▶ Function Tests). The preliminary diagnosis
and a preliminary plan of treatment are discussed.
Generally, however, we limit the information that is given at
this stage. We explain to the patient that we will discuss
the findings and the treatment at length at the next visit,
when the results of all examinations are available. A
standard leaflet about nasal surgery procedures may be
handed out, provided that the patient is informed about the
operation that is most likely indicated.
The second visit is focused on the results of the
photography, imaging, and function tests. The complaints
are reviewed and the examination of the nose and analysis
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of the face are repeated. Endoscopy is carried out (after
decongestion). The findings are then summarized and a
treatment proposal is made and explained. The advantages
and disadvantages of general versus local anesthesia are
discussed. At this time, the benefits and risks of surgery
should be discussed (see following text). The patient is also
informed about the practical aspects of surgical
intervention (e.g., hospital admission or day surgery, length
of stay, postoperative care and follow up, rules to be
adhered to when back home, period of not working, etc.). It
is advisable to write down in the patient’s medical record
the most important considerations and decisions in order to
avoid later misunderstandings. In some cases, we like to
read them aloud to the patient while writing.
Treatment Plan
A treatment plan is drawn up and discussed with the
patient. The surgical procedure is explained, including the
risks and benefits of the operation, as extensively dealt
with in the section on ▶ Preoperative Care on. An information
leaflet and consent form are handed to the patient. It is
advisable to have a relative of the patient present during
this second visit to help avoid any misunderstandings.
Visual Analogue Scoring of Complaints and Rating
Scales of Quality of Life
Visual Analogue Scoring Scale
Over the past two decades, it has become more and more
common to express the degree of a patient’s complaints in
numbers instead of using adjectives such as “light,”
“moderate,” “severe,” “very severe,” and so on. Staging the
severity of a complaint on a numeric scale, a so-called
visual analogue scale (VAS), allows a more scientific
evaluation of the effect of a certain treatment. Numbers
allow a statistical analysis, so that the effect of a therapy
can be expressed quantitatively. Scales ranging from 1 to 5
or from 1 to 10 are both generally accepted. Using this
method, the effect of a surgical procedure can be
quantified and the effectiveness of a new drug can be
compared with that of placebo, for example. Also, the use
of a VAS may be helpful in treating an individual patient.
We use this method to investigate the effect of a
conservative treatment, for example the effect of a
corticosteroid spray on breathing obstruction caused by
turbinate hyperplasia. When the effect appears to be
insufficient, this will help both the surgeon and the patient
to decide on a surgical reduction of the turbinate.
Quality of Life Scale
Similarly, it has become customary to test the results of
treatment using a “quality of life scale.” Patients are asked
to rate various aspects of health and well-being numerically
before and after therapy.
“The patient must be interviewed... By means of questions it
is possible to learn a great deal concerning the illness, which
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enables better treatment.” (Rufus, leading physician at
Ephesus Medical School, 1st century AD)
2.3.2Examination
Inspection and Palpation
In medical examination, inspection precedes palpation.
However, when examining the nose, inspection and
palpation are usually carried out simultaneously. Inspection
requires a light, which is not too bright, so that shadow
effects and light reflexes remain visible. It is important to
illuminate the nose from different angles by moving the
patient’s head. This is the best way to visualize scars,
irregularities, asymmetries, dimples, and grooves. Special
attention is drawn to reflection lines and shadow areas (▶
Fig. 2.123).
Fig. 2.123Inspection of the external nose using reflection of light. Note the bilateral
and symmetrical dorsal reflex lines and dome reflexes.
There are two ways to palpate the nose: by gently stroking,
and gently pressing. Stroking gently with the index finger
will reveal irregularities and defects of the skin, bone, and
cartilage. The quality of the feeling gives information about
the thickness and condition of the skin and the
subcutaneous tissues. Both index fingers, or one index
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finger and the thumb, are used to palpate for symmetry.
Gentle pressure is applied to investigate the stiffness,
mobility, and support of the various nasal structures. The
bony dorsum is examined with the index finger (▶ Fig.
2.124), the bony pyramid with two or three fingers (▶ Fig.
2.125 and ▶ Fig. 2.126). The cartilaginous dorsum and the
nasal tip (domes) are examined for projection and support
by applying gentle (rhythmic) downward pressure with the
index finger (▶ Fig. 2.127). The columella and the position of
the caudal end of the septum are examined by lifting the tip
with the thumb (▶ Fig. 2.128). The ala is examined by gentle
palpation between the index finger and the thumb (▶ Fig.
2.129). All elements of the external pyramid should be
examined in the front view, both side views, and the base
view (see box Specific Aspects of the Nasal Pyramid to be
Examined).
Specific Aspects of the Nasal Pyramid to be
Examined
Front view
Length and width in relation to face
Side view
Length in relation to forehead and chin
Prominence (projection) of bony pyramid, cartilaginous
pyramid, and tip
Angles: frontonasal and nasolabial
Profile: humps, saddling, sagging, irregularities
Columellar position and columellar base in relation to
alar rim
Grooves and dimples
Base view
Projection of lobule and tip
Width, configuration, and symmetry of nares, columella,
alae, vestibulum, and valve
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