Nasal surgery in patients with granulomatosis is complex. A number of considerations are required including the risk of potential reactivation of vasculitis in the operative field after surgery, the tissue quality leading to less predictable healing, and the associated risk of postoperative infection. These are particularly relevant in nasal reconstruction and underscores the need for a multidisciplinary approach.
Management which confers stable, predictable outcomes is advantageous. In this article, we share our experience of the use of endoscopic sinus surgery (ESS) and nasal reconstruction in these difficult cases. In all cases, patients were jointly managed by a reconstructive rhinologist and a vasculitis physician.
Introduction: Complex reconstructive septorhinoplasty requires harvesting a large amount of tissue for grafting. Autogenous costochondral and auricular cartilage has generally considered the gold standard grafting material, if insufficient septal cartilage remains. The aim of this paper was to describe our technique and report our experience with the use of costal cartilage grafts in cases with significant nasal deformities with insufficient septal cartilage.
Design: Retrospective review of patients who underwent septorhinoplasty with costochondral grafts between 1995 and 2015.
Results: Over a 20-year period from 1995 to 2015, a total of 711 rhinoplasties were carried out at Aintree University Hospital, Liverpool. Of these, 46 (5.7%) utilized costal cartilage as the material to provide skeletal support. Male to female ratio was 2:1, and mean age was 34 years (15–56); 22 presented with congenital deformity and 24 with acquired deformity. All had severe nasal collapse (grades III and IV).
Conclusion: Costal cartilage is the ideal material for reconstruction of severe saddle noses. There are no crossinfection risks, the donor site is low morbidity, it is easy to harvest, has a plentiful supply, and is easy to carve and sculpt. The tendency to warping is a disadvantage, but this can be prevented in most cases by careful attention to technique, and is usually easy to correct by minor revision where necessary. It is usually dimensionally stable and is able to resist infection, and where exposure occurs due to wound breakdown, it will heal without total graft loss.
As we move into the era of personalized medicine, there has been considerable progress made toward an increasingly sophisticated understanding of chronic rhinosinusitis. Precise understanding of the pathophysiology and natural history of the disease has unlocked a novel range of therapeutic options, both medical and surgical. This literature review aims to appraise some of these developments, including the utility of monoclonal antibodies, office based procedures such as balloon sinuplasty and steroid-eluting stents, and adjuncts to surgery such as image guidance. In reviewing the evidence for these novel interventions we aim to provide an insight to the tools which may become commonplace in the arsenal of the rhinologist of the future.
Endonasal approaches to the frontal sinuses have evolved rapidly over the past 40 years and with ongoing improvements in technology continue to do so. However, clinical situations remain where the rhinologist will be faced with pathology more appropriately treated through open or combined approaches. This article summarises the current approaches, both open and endonasal.
Operating on the maxillary sinus has been a part of the otorhinolaryngologist's surgical repertoire being perceived as the most accessible sinus. Following the advent of endoscopic sinus surgery and advances in angled endoscopes and surgical instruments, approaches to the maxillary sinus have evolved leaving open approaches largely redundant. This review article will guide the readers through the key anatomical principles and techniques available for endoscopic approaches to the maxillary sinus.
Colin R Butler,
Daniel W Scholfield,
Peter M Clarke
Juvenile angiofibromas are benign, highly vascular lesions that are found in young male patients with an incidence of approximately 1: 150,000. They are thought to arise from a residual vascular plexusin the pterygopalatine fossa at the aperture of the pterygoid canal, as a remnant of the involution of the first branchial arch artery. Juvenile angiofibromas remain challenging to treat. Early staged disease can be adequately treated by endoscopic approaches and with increasing experience, even higher staged disease has been shown to be resectable
In this article the authors discuss the assessment of patients undergoing septorhinoplasty emphasing the importance of psychological assessement in the preoperative work up. Patients motivations, anxieties and expectations are reviewed, key points to help identify problem patients are highlighted and specific questions to identfy those that may be suffering BDD are recommended. Facial proportions and the ideal angles of the facial esthetic triangle are described. A framework is presented to enable systematic analysis and examination of the face and nose to promote appropriate patient selection and facilitate surgical planning.