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This technique is a more precise method and is therefore
preferred for clinical research. In daily practice, however,
this method is less suitable. It is more cumbersome and
requires the assistance of a department of nuclear
medicine.
2.4.5Allergy and Hyperreactivity Testing
The diagnosis of allergic rhinitis is based on the presence
of two or more nasal symptoms and the demonstration of
sensitization, preferably by skin prick testing. The patient
is asked about any of the following reactions:
Nasal symptoms like nasal congestion, rhinorrhea,
secretions, and itchy nose
Ocular symptoms like itchy eyes, tearing and/or
conjunctival vascular dilation
Bronchial symptoms like cough, shortness of breath,
and wheezing
Cutaneous problems like atopic eczema, itchy and red
skin
General problems like impaired sleep, disturbed
concentration and/or reduced physical activity
The patient is also interviewed about abnormal nasal
responses to specific stimuli such as temperature changes,
air pollution (smoke, dust), food, drink, and light.
Allergy testing is an integral part of the routine diagnosis
of patients with nasal mucosal disease. Skin prick testing
(SPT) remains the diagnostic procedure. When there is
discrepancy between history and SPT outcomes, or when
SPT is not feasible or available, allergen-specific IgE should
be determined. Allergen provocation is only advocated in
patients where the association between allergen exposure
and induction of symptoms needs to be clarified, such as
occupational disease, or prior to starting immunotherapy.
Hyperreactivity may be tested by provocation of the nasal
mucosa with histamine (histamine diphosphate 330
µg/nostril), methacholine, or cold dry air. These tests have
not yet come into clinical practice due to their timeconsuming nature.
Techniques Used in Nasal Provocation
The solutions to be used are prepared and administered
according to the guidelines of the IRS as published in 2000.
(1)
Nasal response is assessed by determining symptom scores
(using a VAS scale) in combination with objective
measurement of nasal patency, the amount of secretion,
and the number of sneezes.
Several methods can be used to quantify the effects of
provocation on nasal patency and airflow: anterior or
posterior rhinomanometry, acoustic rhinometry or PNIF.
Each method has its intrinsic advantages and
disadvantages that should be taken into account.
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(1) It is advised to follow the recommendations of the Standardization
Committee on Objective Assessment of the Nasal Airway. See Clement PA.
Committee report on standardization of rhinometry. Rhinology 1984;22:151–55
and Consensus report on acoustic rhinometry and rhinomanometry. Rhinology
2005;43:169-79.
Chapter 3
Surgery—General
3.1 Concepts of Functional Reconstructive Nasal
Surgery
3.2 Endonasal versus External Approach
3.3 Preoperative and Postoperative Care
3.4 Anesthesia and the Bloodless Surgical Field
3.5 Antibiotics and Corticosteroids in Nasal Surgery
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3Surgery—General
3.1Concepts of Functional Reconstructive
Nasal Surgery
3.1.1Surgery for Function and Form
The primary objective of nasal surgery should be to restore
nasal function. The nose evolved to facilitate smelling and
breathing, to detect odors, to control the inspiratory and
expiratory airstream, to humidify and warm inspired air,
and to serve as the first line of defense of the respiratory
tract. These functions are taken care of by the interaction
between the inspired air and the mucous membranes. This
interaction is made possible by the complex airflow through
the nose, determined by the geometry of the internal nose
and by its external form. Therefore, all nasal surgery deals
with function and aesthetics at the same time.
Nowadays, a large proportion of all nasal surgery is done in
pursuit of the elusive goals of beauty and happiness. It is
telling that most books on nasal surgery that have
appeared over the past decades are devoted to cosmetic
rhinoplasty. No matter how legitimate the pursuit of beauty
may be, the nasal surgeon should be aware of the limits of
surgery. If a person’s nose is considered “normal” with
respect to their ethnic origin, gender, and age, changing its
features may run counter to medical ethics. Even in today’s
civilization, the primary objective of nasal surgery must be
to restore function. The goal of functional improvement
must always be given priority over that of enhancing
beauty (▶ Fig. 3.1).
Fig. 3.1Interrelationship between form, function, and aesthetics in nasal surgery.
Aesthetics and form are identical, while function is dependent on form. Function and
aesthetics usually complement each other; however, they may be in opposition. In this
case, surgery for function should prevail over surgery for aesthetics.
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“There could be something insincere about changing a
nose.” Arthur Miller “After the Fall” (1964)
3.1.2Concepts
Nasal surgery or rhinoplasty should be functional and
reconstructive. In the words of Kern, we must try to
“recreate normality.” We attempt to restore function by
reconstructing normal anatomy.
“In functional reconstructive nasal surgery we try to recreate
normality.” Eugene B Kern
Septal deformities are corrected and septal defects are
reconstituted; a deviated bony and cartilaginous pyramid is
straightened; a distorted nasal valve is corrected;
irreversible hypertrophy of a turbinate is reduced. All
tissues are handled conservatively and preserved whenever
possible. Resections should be limited. Tissue is only
removed where necessary for repositioning and
reconstruction. A special effort is made to preserve
mucosal membrane, the functional organ of the nose. If the
turbinates are to be reduced, the required reduction in
volume is achieved by a method that ensures preservation
of their function.
3.1.3Basic Principles
To achieve our goals of reconstituting function and form,
we apply the following three basic principles:
1. The septum and pyramid are corrected in one
procedure. Apart from exceptional cases, septal and
pyramid pathology are addressed in one procedure. A
deviated pyramid is nearly always combined with some
type of septal pathology. The bony pyramid can
therefore only be successfully repositioned after
mobilization and repositioning of the septum. Similarly,
deformities of the cartilaginous pyramid can only be
adjusted after mobilization of the septum. A saddle
nose is another example. First, the septum has to be
rebuilt to provide support for the dorsum, tip, and
columella. Second, the pyramid is mobilized and
repositioned. Finally, the lobule is modified as required,
and adjusted to the new septum and pyramid. If a
transplant is to be inserted to augment the nasal
dorsum, this is performed as the final step.
2. The lobule is preferably modified in the same
procedure as the septum and the external pyramid. In
most cases, it is advisable to correct the lobule
together with the septum and pyramid in the same
surgical procedure. Limited and moderate
modifications such as narrowing the tip, increasing or
decreasing tip projection, and upwardly rotating the tip
can be performed very well in the same operation. In
patients with a more severe lobular deformity, it is
better to postpone lobular surgery for a second
operation. In special cases, additional dorsal
augmentation (saddle nose) or additional lobular
refinement may be indicated at a later stage. This type
of refinement surgery should not be carried out before
healing is completed (i.e., not earlier than 9 to 12
months after the previous operation).
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3. In patients with extensive pathology, surgery may be
performed in two stages. In cases with extensive
pathology (e.g., cleft-lip nose, congenital hypoplasia, or
severe saddle nose), surgery is planned from the
beginning in two or even three stages. This may also be
advisable in difficult revision cases. The septum and
pyramid are then addressed in the first operation and
the lobule in the second.
3.2Endonasal versus External Approach
3.2.1Historical Development
Surgery of deformities of the external nasal pyramid
commenced in the second half of the 19th century using
external incisions ([348]). The introduction of the endonasal
approach to correct a dorsal hump and a bulbous
prominent tip by John Orlando Roe of Rochester, New York
(1887) was a great step forward. This method was further
developed by others, in particular Jacques Joseph in Berlin
in the first decade of the 20th century.
In the 1920s, Réthi of Budapest and Gillies of London
introduced an approach to the nasal dorsum through an
incision at the lobular base. Although this method did not
have many followers, it was never completely forgotten
(e.g., Šerçer 1957, 1962; see ▶ The External Approach).
In the 1970s, when almost all nasal surgeons were satisfied
with the endonasal approach to various nasal deformities,
the external approach was reintroduced. Within a few
years, the “open approach” became very popular because it
allows “open structure surgery.” The external approach
through a midcolumellar incision proved to be a great step
forward, particularly in correcting lobular pathology.
3.2.2Advantages and Disadvantages of
the Two Different Approaches
Both the endonasal and the external approach have their
advantages and disadvantages. Which method to use in an
individual case depends on various factors: first, the type of
pathology and the surgical goals; and second, the surgeon’s
personal preference and surgical experience.
There is no such thing as a “typical” or “standard”
rhinoplasty.
In general, surgery should be performed with as little
trauma as possible provided that access to the surgical
field is sufficiently wide to work safely. Since the endonasal
approach is less traumatic to the columella, nasal tip, and
dorsum, we could say: “What can be done endonasally
should be done endonasally.”
Although avoiding external incisions is an additional
argument in favor of the endonasal approach, stab incisions
for osteotomies and broken columellar incisions for the
open approach have proven free from significant problems.
The external approach is therefore preferred when a wide
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