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Rhinoplasty Bizrah: Septoplasty Turbinectomy 1

March 27, 2017 by basharbizrah0

Possible complications:

  1. Early septal haematoma and abscess formation:
    Manage by drainage and antibiotic cover.
  2. Loss of smell:
    Allergic rhinitis and neuro-vascular reflexes may cause loss of sense of smell. Also due to fracture of the olfactory plate caused by excessive pulling on the septum.
  3. Supratip collapse:
    Caused by dislocation of the dorsum bone-cartilage junction as the result of excessive pulling on the septum or due to leaving a narrow dorsum strut. Managed by supratip conchal graft. (Fig. 9 – 8 and Figs. 13 – 11,12)
  4. Columellar retraction:
    Due to overtrimming of the caudal septum. Managed by columellar strut.(Fig. 13 – 12)
  5. Dropped tip:
    Due to excessive trimming of the superior septal angle, dorsum and caudal septum and the use of full transfixion incision. Managed by tip plasty of new dome creation, scoring, suture fixation, columellar strut, tip graft and septocolumellar sutures.

Fig. 16 – 5. (1) Enlarged inferior turbinate (2) Nasal septal spur (3) Deviated nasal septum (4) Enlarged middle turbinates (concha bullosa)

 

Fig. 16 – 6. Correction of caudal dislocation achieved by septoplasty, conservative caudal trimming of the septum and columellar strut inserted between the two medial crura.

 

  1. Septal perforation:
    Due to injury of the bilateral flaps. Prevented by accurate identification of the right plane of dissection which should be subperichondreal and subperiosteal and by meticulous slow dissection.
  2. Complications of postoperative infection:
    Bleeding _ adhesions _ polyps formation or very rarely, intra-cranial spread of infection by the emissary veins causing multiple abscess formation.

 

 

  1. TURBINECTOMY

 

Turbinectomy was first described by Jones in 1895. In 1900, Holmes described his experience with over 1,500 patients. Freer in 1911, reported that there was no atrophic rhinitis noted following turbinectomy but there was prolonged crustation.

 

Septal deviation is often associated with hypertrophy of the inferior turbinates. The hypertrophy often involves mucosa and bone. Trimming is best achieved by right angle turbinectomy scissors with the cut being made through the mucosa and bone, in order to obtain long term airway relief. Recently, the C02 and KTP lasers have been used to remove the thickened mucosa, most authors (Selkin, Jukutake, Levine) reported nasal airway improvement for only up to one year after surgery.

Partial trimming on Inferior Turbinates

  1. Should be the last step of rhinoplasty procedure.
  2. First, infracturing the turbinate using Hill’s or Freer’s elevator.
  3. Do partial trimming:
    A useful tip is not to remove too much or too little, holding turbinectomy scissors at a 450 angle on the turbinates directed posterior and inferior and then to cut through mucosa and bone.
  4. Remove trimmed portion of the turbinates in one piece by wide forceps. Avoid removing turbinates in pieces as this will cause necrosis, infection and bleeding.
  5. Ensure that the anterior end is adequately trimmed. A bulky anterior end will cause obstruction even if most of the middle or posterior end of the turbinates are removed. The nasal cavity gets wider posteriorly so there is no point in excessive trimming of the middle and posterior portions. In 1984, a study of 408 patients by Rohrich, showed that removal of the anterior two thirds of the inferior turbinate was sufficient to relieve nasal obstruction. (Fig. 17 – 19)
    1. Use the endoscope. This will allow accurate trimming of the anterior, middle and posterior portions of the inferior turbinates in one piece. It helps to avoid remnants, in particularly the posterior end which if left behind may cause early postoperative bleeding and later airway obstruction.
    2. Use light nasal packs of two small Sofratulle (10cm x 10cm) on each side. It has been reported that there is increased intraoperative or postoperative bleeding, however, the author has not found this to be the case. The percentage of bleeding in turbinectomy with rhinoplasty is less than that for turbinectomy alone, because the nose is preoperatively well prepared by nasal constrictors and the pressure applied on the turbinates is doubled by the nasal pack inside and the cast on the outside. The author’s percentage of postoperative bleeding is approximately one in sixty.
    3. Use intranasal splints:
      Shaped sterile x-ray sheets or Shah intranasal splints are routinely used in our practice, when septorhinoplasty is combined with turbinectomy in order to avoid postoperative adhesions.

    Possible complications:

    1. Intraoperative and postoperative bleeding.
    2. Prolonged crustations:
      Manage by daily nasal wash. Sea water sprays are recommended.
    3. Adhesions:
      The use of intranasal splints reduce this problem. Manage by division and resplinting for two weeks. Postoperative infection is a main cause of adhesions.
    4. Problems related to excessive trimming:
      Continuous sore throat, feeling of blocked nose and crustation.
    5. Rarely, atrophic rhinitis:
      Turbinectomy should be avoided in patients with a previous history of crustation. Cautiously, limited trimming should be performed on patients living in a dry climate and in high altitude towns.
    6. Loss of sense of smell:
      This is very rare, but it has been reported in the literature. It could be due to allergic rhinitis or neuro-vascular reflexes during removal of the turbinates causing severe vasoconstriction leading to ischaemia of the olfactory neural ends. Blindness has also been reported due to reflexes and constriction of the retinal artery causing retinal damage.

Refrences
Septoplasty — Turbinectomy
 

1. Beekhuis GJ: Nasal septoplasty. Otolaryngol Clin North Am 6:693, 1973.
2. Beekhuis GJ: Nasal obstruction after rhinoplasty:Etiology and techniques for correction. Laryngoscope 86:540, 1976.
3. Bernstein L: Submucous operations on the nasal septum. Otolaryngol Clin North Am 6:675-692, 1973.
4. Berry RB: Nasal resistance before and after rhinoplasty. Br J Plast Surg 34:105, 1981.
5. Bull T: Septoplasty vs. SMR. J Larymgol Otol (suppl) 8:108-112, 1983.
6. Bumstead: Cryotherapy for chronic vasomotor rhinitis: Technique and patient selection for improved results. Laryngoscope 94:539-544, 1984.
7. Courtiss EH, Goldwyn RM, O’Brien JJ: Resection of obstructing inferior nasal turbinates. Plast Reconstr Surg 62:249-251, 1978.
8. Courtiss EH, Goldwyn RM: The effects of nasal surgery on airflow. Plast Reconstr Surg 72:9, 1983.
9. Freer OT: The inferior turbinate: Its longitudinal resection for chronic intumescence. Laryngoscope 21:1136, 1911.
10. Goldman IB: New techniques in surgery of the deviated nasal septum. Arch Otolaryngol 64:183-189, 1956.
11. Goldman IB: Rhinoplastic sequelae causing nasal obstruction. Arch Otolaryngol 83:151, 1966.
12. Goode RL: Surgery of the turbinates. In Krause CJ, Mangat DS, Pastorek N (eds.): Aesthetic Facial Surgery ed.1. Philadelphia, JB Lippincott, pp 161-173.
13. Holmes CR: Hypertrophy of the turbinated bodies. NY Med J 72:529, 1900.
14. House HP: Submucous resection of the inferior turbinal bone. Larungoscope 61:637-648, 1951.
15. Jone M: Turbinal hypertrophy. Lancet 2:879, 1985.
16. Levine HL: the potassium-titanyl phosphate laser for treatment of turbinate dysfunction. Otolaryngol Head Neck Surg 104:247-251, 1991.
17. Mabry RL: Intraturbinal steroid injection: Indications, resilts, and complication. South Med J 71:789-791, 1978.
18. Mabry RL: Corticosteroids in otolaryngology: Intraturbinal injection. Otolaryngol Head Neck Surg 91:717-720, 1983.
19. Mabry RL: Inferior turbinaplasty: Patient selection, technique and long-term consequences. Otolaryngol Head Neck Surg 98:60-66, 1988.
20. Maran AG: the role of septoplasty and the submucous resection. Clin Otolaryngol 4:307-314, 1979.
21. Martinez SA, Nissen CR, Stock CR, et al: Nasal turbinate resection for relief of nasal obstruction. Laryngoscope 93:871-875, 1983.
22. McKinney P, Shively R: Straightening the twisted nose. Plast Reconstr Surg 64:176-179, 1979.
23. Moore GF, Freeman TJ, Ogren FP, et al: Extended follow-up of total inferior turbinate resection for relief of chronic nasal obstruction. Laryngoscope 95:1095-1099, 1985.
24. Morgenstein KM, Krieger MK: Experiences in the middle turbinectomy. Laryngoscope 93:871, 1983.
25. Oakley,S., Adamson, P.,Tropper, Cole, P, Becky, McGram. The role of partial turbinectomy in aesthetic septorhinoplasty.
26. Paterson CN: Surgery of the crooked nose. Laryngoscope 91:939-944, 1981.
27. Pollack RA, Rohrich RJ: Inferior turbinate surgery: An adjunct to successful treatment of nasal obstruction in 408 patients. Plast Reconstr Surg 74:227-236, 1984.
28. Rees T: surgical correction of the severely deviated nose by extramucosal excision of the asseocartilagenous septum and replacement as a free graft. Plast Reconstr Surg 78:320-330, 1986.
29. Richardson JR: Turbinated treatment in vasomotor rhinitis. Laryngoscope 58:834-837, 1948.
30. Selkin SG: Laser turbinectomy as an adjunct to rhinoplasty. Arch Otolaryngol 111:446-449, 1985.
31. Tremble GE: Methods of shrinking the inferior turbinate to improve the airway. Laryngoscope 70:175, 1960.

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