Functional Rhinoplasty

Author Credentials 

Nicholas B Abt, MD and Robin W. Lindsay, MD
Department of Otolaryngology
Massachusetts Eye and Ear Infirmary
Harvard Medical School

 

Module Summary

Nasal obstruction can have multiple anatomic causes. This can include septal deviation, turbinate hypertrophy, and nasal valve compromise.  Functional septorhinoplasty is a procedure performed to correct dorsal and caudal deviation of the septal L-strut and nasal valve compromise.  Nasal valve compromise can be cause but narrowing of the internal or external nasal valves and/or collapse of the lateral nasal side wall.  All of these potential etiologies should be considered during the evaluation of a patient presenting with nasal obstruction.

Module Learning Objectives 
  1. Review anatomic causes of nasal obstruction.
  2. Explain the clinical evaluation of nasal obstruction including physical exam as well as objective and patient reported outcome measures.
  3. Describe principles and techniques to relieve nasal obstruction.

 

Evaluation and Surgical Options

Evaluation

  1. Review anatomic causes of nasal obstruction.
  • Deviated septum
  • Turbinate Hypertrophy 
  • Nasal Valve Compromise 
  1. Explain the clinical evaluation of nasal obstruction 
  • Patient Reported Outcome Measures
    • Nasal Obstruction Symptom Evaluation Score (NOSE score)1,2
    • FACE-Q Rhinoplasty3
    • 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for Functional and Cosmetic Rhinoplasty4
  • Objective Outcome Measures5
    • Nasal Inspiratory Flow Meter (PNIF)6,7
    • Rhinomanometry8
    • Computation Fluid Dynamics 
  • Physical Exam9
    • Nasal external appearance
    • Narrow middle vault
    • Deviated Nasal Dorsum
    • Cephalic malrotation of the lateral crura
    • Medial crural flare
    • Lateral nasal side wall collapse on inspiration10
  • Intranasal examination11
    • Anterior rhinoscopy
    • Nasal endoscopy 
  • Modified Cottle Maneuver
  • Palpation of Dorsum and Caudal Septum

 

Surgical options

  • Summarize principles and techniques to relieve nasal obstruction:
  • There are many techniques that have been described for the correction of nasal valve compromise. A selection of the most common techniques is listed below. 
  1. Identify anatomic defects requiring functional septorhinoplasty12
  • Caudal septal deviation
    • Swinging door technique
    • Modified extracorporeal septoplasty technique13
  • Dorsal septal deviation
    • Extended spreaders
    • PDS plate14
    • Modified extracorporeal septoplasty technique13
    • Release and repositioning of mispositioned components
  • Internal nasal value narrowing
    • Spreader grafts in submucosal pocket between septum and upper lateral cartilage (ULC)15
    • Butterfly graft via conchal cartilage16
      • Positioned superficial to ULC and deep to lower lateral crura
    • Autospreader graft17
  • External nasal valve narrowing 
    • Correction of medial crural flare
    • Alar rim grafts/ alar contour grafts
  • Lateral nasal side wall collapse
    • Alar batten grafts18
    • Lateral crural strut grafts19,20
    • Alar rim grafts/ alar contour grafts21
  • Mid Septal Deviation
    • Release of bony cartilage junction and reposition.
    • Release off maxillary crest and reposition
    • Division, morselization, deflection correcting splint grafts

 

References

  1. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157-63.
  2. Rhee JS, Sullivan CD, Frank DO, Kimbell JS, Garcia GJ. A systematic review of patient-reported nasal obstruction scores: defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg 2014;16:219-25; quiz 32.
  3. Klassen AF, Cano SJ, East CA, et al. Development and Psychometric Evaluation of the FACE-Q Scales for Patients Undergoing Rhinoplasty. JAMA Facial Plast Surg 2016;18:27-35.
  4. Moubayed SP, Ioannidis JPA, Saltychev M, Most SP. The 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for Functional and Cosmetic Rhinoplasty. JAMA Facial Plast Surg 2018;20:37-42.
  5. Mohan S, Fuller, J. Ford, S., Lindsay, R. . Advances in Diagnosis and Treatment: Nasal Obstruction JAMA Facial Plast Surg 2018.
  6. Fuller JC, Bernstein CH, Levesque PA, Lindsay RW. Peak Nasal Inspiratory Flow as an Objective Measure of Nasal Obstruction and Functional Septorhinoplasty Outcomes. JAMA Facial Plast Surg 2018;20:175-6.
  7. Timperley D, Srubisky A, Stow N, Marcells GN, Harvey RJ. Minimal clinically important differences in nasal peak inspiratory flow. Rhinology 2011;49:37-40.
  8. Pawar SS, Garcia GJ, Kimbell JS, Rhee JS. Objective measures in aesthetic and functional nasal surgery: perspectives on nasal form and function. Facial Plast Surg 2010;26:320-7.
  9. Colaianni CA, Levesque PA, Lindsay RW. Integrating Data Collection Into Office Work Flow and Electronic Health Records for Clinical Outcomes Research. JAMA Facial Plast Surg 2017;19:528-32.
  10. Tsao GJ, Fijalkowski N, Most SP. Validation of a grading system for lateral nasal wall insufficiency. Allergy Rhinol (Providence) 2013;4:e66-8.
  11. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 2010;143:48-59.
  12. Barrett DM, Casanueva FJ, Cook TA. Management of the Nasal Valve. Facial Plast Surg Clin North Am 2016;24:219-34.
  13. Most SP. Anterior septal reconstruction: outcomes after a modified extracorporeal septoplasty technique. Arch Facial Plast Surg 2006;8:202-7.
  14. Fuller JC, Levesque PA, Lindsay RW. Polydioxanone plates are safe and effective for L-strut support in functional septorhinoplasty. Laryngoscope 2017;127:2725-30.
  15. Sheen JH. Rhinoplasty: personal evolution and milestones. Plastic and reconstructive surgery 2000;105:1820-52; discussion 53.
  16. Loyo M, Gerecci D, Mace JC, Barnes M, Liao S, Wang TD. Modifications to the Butterfly Graft Used to Treat Nasal Obstruction and Assessment of Visibility. JAMA Facial Plast Surg 2016;18:436-40.
  17. Yoo S, Most SP. Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument. Archives of facial plastic surgery 2011;13:231-3.
  18. Toriumi DM, Josen J, Weinberger M, Tardy ME, Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 1997;123:802-8.
  19. Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope 2012;122:1480-8.
  20. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg 1997;99:943-52; discussion 53-5.
  21. Rohrich RJ, Raniere J, Jr., Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 2002;109:2495-505; discussion 506-8.
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