Head & Neck Surgery - Otolaryngology
4th Edition

23
Surgical Management of Septal Deformity, Turbinate Hypertrophy, Nasal Valve Collapse, and Choanal Atresia
Michael Friedman
Ramakrishnan Vidyasagar
Nasal obstruction is a common presenting symptom in the practice of otolaryngology. The most common diagnoses of nasal obstruction are presented in Table 23.1. Sometimes multiple contributing processes cause nasal obstruction. Strategies for the management of nasal obstruction are based primarily on history, physical examination, and results of laboratory tests, where applicable. It should also be understood that some of the obvious findings, such as septal deviation, may not be the only contributing cause for the nasal obstruction, and may just be an incidental finding. Care should always be taken to analyze the patient as a whole, rather than the nose as a separate organ. Patients with systemic disorders [such as obesity, hypothyroidism, obstructive sleep apnea/hypopnea syndrome (OSAHS), and Sjögren syndrome] can present with nasal obstruction as a part of their medical disease with or without any localized nasal finding. A thorough assessment of all potential causes of nasal obstruction is essential before definitive treatment of a single anatomic obstruction.
Several factors may influence the sensation of comfortable nasal breathing, including the amount and type of nasal airflow, the sensation registered from the intranasal skin or mucosa by the passing air, and the condition of the nasal mucosa. Many physiologic and pathologic conditions affect the amount of airflow through the nose. The nasal pathologic conditions include mucosal hyperactivity, septal or other structural deformities, polyps, tumors, sinus infection, granulations, and synechiae. Any one of these or many of these together may be the factors that limit airflow in a person who complains of nasal obstruction.
History
The first step in assessing any symptom is to obtain a thorough history. The clinician should pay particular attention to the time of onset, severity and duration of symptoms, and recourse the patient has taken to alleviate symptoms. The history should determine if the obstruction is unilateral, bilateral, or alternating; the duration of the obstruction (recurrent or chronic); aggravating factors;
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and contributing factors in the patient’s environment. A complete history also includes the presence or absence of the following symptoms: (a) rhinorrhea, if any, that includes characteristics such as purulence, odor, consistency, and color; (b) epistaxis or blood in the nasal secretions; (c) nasal pain, or facial or orbital pain; and (d) middle ear disease or symptoms relating to the middle ear. The past medical history should focus on (a) respiratory illness, such as chronic obstructive pulmonary disease or asthma; (b) any allergy; (c) drug, alcohol, or tobacco use; (d) nasal surgery or trauma; and (e) current use of medications, especially nasal corticosteroids, aspirin, or other medications that alleviate or exacerbate symptoms of nasal obstruction.
TABLE 23.1 COMMON CAUSES OF NASAL OBSTRUCTION
Diagnosis Symptoms Test
Allergy Bilateral nasal obstruction, history of seasonal obstruction, pale or bluish nasal mucosa Skin tests, RAST, food allergen testing
Vasomotor rhinitis Clear, glary mucus Rule out other causes
Septal deviation Septal deviation at physical examination, unilateral nasal obstruction CT of sinuses and septum
Turbinate hypertrophy Turbinate enlargement (usually inferior) at physical examination Direct inspection
Polyps Unilateral or bilateral nasal obstruction, impaired sense of smell Direct inspection
Valvular collapse Nasal “valvular” collapse on deep inspiration Cottle test, observation of deep inspiration
Sinusitis Mucopus on anterior rhinoscopy, pain during percussion of involved sinus CT of sinuses
Adenoid hypertrophy Unilateral or bilateral nasal obstruction, mouth breathing, snoring, crowding of teeth Posterior rhinoscopy, nasal endoscopy, x-ray nasopharyngeal-lateral view
OSAHS Thick palate, hypertrophic tonsils Polysomnography
Septal perforation Septal perforation at physical examination Direct inspiration
Neoplasm Obvious mass at physical examination CT scan of sinuses, biopsy
Choanal atresia Unilateral or bilateral nasal obstruction with clear rhinorrhea Sagittal CT through nasopharynx
CT, computed tomography; OSAHS, obstructive sleep apnea/hypopnea syndrome; RAST, radioallergosorbent test
Most patients with nasal obstruction describe generalized “stuffiness”; however, nasal obstruction can have more obscure, nonnasal manifestations. Common nonnasal manifestations of obstruction include dry mouth; chronic sore throat; frontal, cheek, or orbital pain indicating acute or chronic sinusitis; localized facial pressure indicating sinusitis; excessive snoring; halitosis; parental concern about a child’s lethargy or disinterest; inability to sleep soundly that results in hypersomnolence during the day; and decreased sense of taste or smell.
Differential Diagnosis
The surgeon should have a complete list of differential diagnoses in mind before proceeding to the physical examination. Systemic diseases that can cause nasal obstruction, such as obesity, hypothyroidism, OSAHS, and Sjögren syndrome, should be excluded before proceeding to the local examination. External factors such as tip ptosis, caudal dislocation of septum, nasal valve obstruction, saddle deformity, and crooked nose should be evaluated. Intranasal causes of nasal obstruction include septal deviation, turbinate hypertrophy, and nasal polyposis. Choanal and nasopharyngeal obstruction may be caused by adenoid hypertrophy, OSAHS, or choanal atresia (Table 23.1). Although no clinical evidence is available to document obesity as a cause of nasal obstruction, it is a common observation that patients with morbid obesity (body mass index greater than 40 kg/m2) have nasal obstruction without obvious anatomic deformities. The presence of systemic factors contributing to nasal obstruction is not a contraindication to correction of identified local areas of obstruction.
Physical Examination
External Contour
A physical examination begins with evaluation of the external nose. This examination is focused on the size and shape of the nose. The presence of any deformity or deviation that displaces the nasal midline laterally is documented. Bony fractures can depress the nasal vault and narrow the radius of the nasal passage, and can cause saddle deformity. Trauma to the distal upper lateral nasal cartilage (the upper lateral wings of the quadrilateral
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cartilage of the nasal septum) can dislocate these cartilages and involve the nasal septum intranasally. A crooked nose or narrow nose and midfacial complex should also be noted. The appearance of a nasal crease on the nasal dorsum suggests frequent nose wiping and upward movement of the nose from chronic or allergic rhinorrhea (allergic salute). Congenital anatomic variation can manifest as thin, weak upper lateral cartilaginous support and an incompetent nasal valve. Tip ptosis and caudal deviation of the septum should be assessed by visual inspection before manipulation. Tip elevation to eliminate ptosis should improve the airway if tip ptosis is a factor.
Nasal Valve
While examining the nasal valve, both the external and the internal valve should be visualized for obstruction. Although the term nasal valve collapse is frequently used, we prefer to identify the problem as nasal valve obstruction, because some patients have fixed obstruction, whereas others have a normal valve area during exhalation and have collapse. Obstruction is on inspiration only. The inclusive term obstruction refers to both fixed and inspiratory obstruction. The internal valve, which is located between the lower border of the upper lateral cartilage and piriform aperture, can be easily distorted during anterior rhinoscopy and completely overlooked with nasal endoscopy; hence, it should be examined before introducing the speculum into the nose. Two types of obstructions are described in the nasal valve area: (a) inspiratory nasal valve obstruction and (b) fixed nasal valve obstruction. The inspiratory valve obstruction occurs only during the inspiration phase, whereas fixed obstruction is evident even at rest. Fixed obstruction and inspiratory obstruction can be present together. Asking the patient to take a deep inspiration while observing the nasal valve will identify inspiratory obstruction, when present. Normally during inspiration, the external dilators of the nose widen the nasal alae and the nasal valve area is widened. In patients with inspiratory nasal valve obstruction, the nasal valve collapses or narrows the nasal valve area. These patients can feel immediate restoration of nasal patency by bilaterally widening the alae with the index finger and thumb (Cottle maneuver). Testing with nasal strips (Breathe Right, CNS, Inc., Whippany, NJ) can also result in an improved airway, by widening of the nasal valve area in patients with nasal valve obstruction.
Tip Ptosis and Caudal Deflectionof the Septum
Tip ptosis is more common in the elderly patient. These patients often complain of diminished nasal airflow due to loss of tip support. These patients often demonstrate to the surgeon that by lifting up their nose they can improve their nasal airway. Factors extrinsic to the septal cartilage itself may also be responsible for the nasal septal deviation. For instance, an abnormally large or lateralized premaxillary spine can cause the displacement of the base of the caudal septal cartilage and in doing so, distort the symmetry of the nasal tip. Sometimes tip ptosis and caudal deflection present external clues to identify the etiology of nasal obstruction. Proper attention and careful examination of the tip may aide in definitive management of patients’ symptoms.
Rhinoscopy
Anterior rhinoscopy can be accomplished with a nasal speculum and head mirror. During anterior rhinoscopy, the examiner documents the characteristics of rhinorrhea; septal deviation; or septal spurs, turbinate hypertrophy, the extent to which the nasal mucosa is edematous or obstructive, and any polyps or mass in the nasal cavity. The examination of the nasal cavity should be done both before and after the application of local decongestants. The reduction in the size of the turbinates and changes in the mucosa should also be documented. The posterior rhinoscopic examination of the nasopharynx and posterior choanae may be accomplished through the oral cavity with a head mirror for illumination and a nasopharyngeal mirror for visualization. During the posterior rhinoscopic examination, the examiner documents the presence or absence of eustachian tube patency, hypertrophic adenoid tissue, and abnormal epithelial lesions. In both examinations, a rigid or flexible fiberoptic nasopharyngoscope can provide superior illumination with magnification and aid in the identification of pathologic conditions of the nasal or nasopharyngeal space. It also provides information about the middle meatus and sphenoid ethmoid recess that would not be seen with anterior and posterior rhinoscopy. It should not, however, be a substitute for external examination and anterior rhinoscopy but should be complimentary to the standard examination.
Muller maneuver is also performed to assess coincidental velopharyngeal narrowing and hypopharyngeal narrowing in suspected OSAHS patients. Examination of the soft palate is essential as well. A thick, soft palate and uvula associated with snoring and OSAHS may be a cause of nasal obstruction even during awake hours. Identification of all areas of obstruction is essential before proceeding to the surgical correction of a single factor.
Investigations
Investigations to assess nasal airway dysfunction depend on the suspected differential diagnosis. In many situations, a thorough history and physical examination are adequate
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to establish a diagnosis and to proceed with a treatment plan.
TABLE 23.2 TREATMENT CHRONIC NASAL OBSTRUCTION
Diagnosis Treatment
Septal deviation Septoplasty
Nasal fracture Reduction
Turbinate hypertrophy Decongestants, turbinoplasty, turbinate resection, radiofrequency reduction, microdebrider-assisted turbinate reduction
Septal perforation Septal button, advancement flaps, inferior turbinate flap
Nasal valve collapse Adhesive supporting strips, naso-orbital suspension of the nasal valve, valvular reconstruction with spreader grafts
Choanal atresia Transpalatal repair, endoscope assisted repair
Neoplasm Resection
Nasal polyposis Polypectomy, topical corticosteroids
Tip ptosis Cartilage graft to support tip
Allergic rhinitis Avoidance of or desensitization to the allergen, antihistamine, topical steroid, etc.; evacuation
Septal hematoma Incision and drainage, antibiotics
Septal abscess Incision and drainage, antibiotics
Nasal foreign body Foreign body removal
Rhinoscleroma Tetracycline early or surgical resection of fibrotic material later
Rhinitis medicamentosa Glucocorticoids (temporary) and avoidance of nasal decongestant sprays
Mucormycosis Radical debridement, antifungal
OSAHS Treatment of obstructive palate and tonsils (uvulopalatopharyngoplasty)
OSAHS, obstructive sleep apnea/hypopnea syndrome.
Roentgenogram of the sinuses has become less helpful in diagnosing the cause for nasal obstruction. Radiologic screening using a computed tomography (CT) scan could provide vital information when inflammatory disease, sinusitis, trauma, neoplastic growth, or congenital abnormality is suspected. A CT scan can also document septal deformity and turbinate hypertrophy but is not essential for the diagnosis.
Acoustic rhinometry and rhinomanometry have been used to objectively assess nasal airway resistance and obstruction since the 1980s. Recently, acoustic rhinometry has more often been used in the objective diagnosis of nasal valve obstruction. Acoustic rhinometry measures the cross-sectional area (CSA) of the nasal cavity, in which a shock wave is presented to the nasal airway and the reflected sound is measured. Recent articles describe the dual-mode acoustic rhinometry in the diagnosis of nasal valve collapse. First, the CSA area is measured when the patient is apneic, and then the CSA measurement is repeated during the inspiration. The ratio between the two is used as a guide to determine if the patient has valve collapse or not. In a normal nasal valve, the inspiratory/apneic CSA ratio should be close to 1.0. A significant drop in CSA during the inspiratory phase will give an inspiratory/apneic CSA ratio of less than 1, indicating inspiratory valve collapse. A very low CSA, measured both in apnea and inspiratory phase, may indicate a fixed valve obstruction. The range of normal CSA, however, is quite large, and therefore any single measurement is not completely diagnostic (1).
Rhinomanometry is a method of simultaneous recording of the transnasal pressure and airflow. This technique of recording pressure and flow simultaneously over a given time interval allows for study of the relationship between pressure, airflow, and time, to give the most complete objective assessment of the passage of air through the nose. Although helpful as support data, neither rhinomanometry nor acoustic rhinometry is considered standard in the evaluation and treatment of septal deformity and valve collapse. Biopsy is indicated when a neoplasm or an unusual inflammatory process, such as fungal infection or Wegener granulomatosis, is suspected.
Management
The most common therapies for nasal obstruction are shown in Table 23.2.
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Deviated Nasal Septum
Deviated septum is the most common cause of nasal obstruction. Among patients with nasal septal deviation, a history of nasal or midfacial trauma often indicates the original alteration of normal nasal anatomic features. Improper forceps placement through an unusually narrow pelvic canal can cause septal deviation early in anatomic development. Internal deviation can be caused by singular or concerted alteration of the bony portion or cartilaginous portion of the septum; however, bony alteration of the posterior septum (the vomer or perpendicular plate of the ethmoid) is less frequent. Patients with unilateral septal deviation may have nasal obstruction of the contralateral side. It is critical for a successful outcome in septal surgery to do a thorough preoperative evaluation that identifies the areas where the symptoms arise. Septal deviations tend to progress over a period of years, and usually symptoms will arise with no clear history of trauma, or many years after trauma.
Clinical Indications
Septoplasty alleviates nasal obstruction by means of surgical resection of impinging anterior cartilaginous or posterior osseous septal deviation. The clinical indications are tabulated in Table 23.3.
Operative Procedure
Septoplasty involves the surgical correction of a deviation of the septum. The surgeon resects only the deviated portion of the septum, allowing maximal preservation of this important structural component of the nose. Whereas the submucosal resection of the septum involves removal of the septum except for a 1-cm wide dorsal and caudal strut that remains for the nasal support, we prefer the concept and term septoplasty, because each procedure should be individualized and limited to conservative resection of abnormal cartilage only.
Septoplasty can be performed with either a local or a general anesthetic. The latter is preferred for operations on patients who are apprehensive about surgery, or when a long procedure such as endoscopic sinus surgery, is combined with septoplasty. The infiltration in the subperichondrial plane is the key step in the operative procedure. This is performed with a hemostatic solution, such as lidocaine 1% with 1:100,000 epinephrine. The infiltration can be done from either anterior to posterior, or posterior to anterior, although the authors prefer the former. Multiple injections may be needed over the spur, but the first injection is the key in elevating the flaps, because the injection must be in the right plane with high pressure to elevate the perichondrium. This is usually accomplished with injection at dorsal anterior injection point. Waiting 10 minutes after injection maximizes the effect of vasoconstriction.
TABLE 23.3 CLINICAL INDICATIONS FOR SEPTOPLASTY
  • Deviation of the nasal septum, with partial or complete unilateral or bilateral obstruction of airflow
  • Persistent or recurrent epistaxis
  • Evidence of sinusitis secondary to septal deviation
  • Headaches secondary to septal deviation and contact points
  • Anatomic obstruction that makes indicated sinus procedures difficult to perform efficiently
  • Obstructive sleep apnea/hypopnea syndrome
  • As an approach to transseptal transsphenoidal approach to pituitary fossa
Incision
Placement of incision depends on the specific area of the septum that needs to be addressed. Freer’s hemitransfixation is preferred if the caudal quadrangular cartilage is dislocated. This incision passes through the membranous septum, between the medial crura of the lower lateral cartilages and the caudal quadrangular cartilage. The Killian incision (vertical incision about 1 to 2 cm from columella) is preferred if the obstruction is in the posterior cartilaginous septum or the bony septum (Fig. 23.1). The third type of incision, is an endoscopic septoplasty incision, in which the incision is made just parallel to the spur that needs to be removed.
The side of incision depends on multiple factors. Usually the right-handed surgeon prefers a left-sided incision. Sometimes, the surgeon may prefer to use the incision on the convex side of the septal deviation. Therefore, even a right-handed surgeon may need to make a right hemitransfixation incision if the caudal septum is convex towards the right. After the incision is made, a mucoperichondrial-mucoperiosteal flap is raised on the side of the incision (Fig. 23.2). The confluence of the septal cartilage, the perpendicular plate of the ethmoid, and the vomer is a difficult area to raise without perforating the mucosa. It requires meticulous dissection with a Freer or Dunning elevator. The mucoperichondrium-mucoperiosteum on the
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contralateral side is also raised. Access to the contralateral side is either via an incision through the septum or around the caudal septum, depending on the exposure required. Deviated portions of the septum are identified and removed. If the cartilage is normal and only a ventral cartilage, maxilla or vomer deformity is the problem, complete flap elevation of the contralateral side is not always essential. A knife is used to incise the cartilage above the ventral deformity. Septal spurs that are due to overgrowth of the maxillary crest can be removed with a Freer chisel. Resection of vomer deformity can be accomplished with an osteotome. Care is taken not to rock the perpendicular plate of ethmoid bone. Rocking can cause fracture at the cribriform plate and can cause cerebrospinal rhinorrhea. Care also is taken to avoid tearing the septal flaps, because bilateral tears can cause septal perforation. Occasionally, torn mucosa and perichondrium can inadvertently be removed with bone and cartilage. Loss of mucosa will obviously delay healing and increase the risk of septal perforation.
Figure 23.1 Hemitransfixion incision made on caudal tip of the septum through mucosa and perichondrium.
Figure 23.2 Elevation of mucoperichondrium flap from septum.
When deviation involves the dorsal strut of the septum or the caudal end of the septum, the initial approach is to release the septum by excision of a small strip of ventral cartilage, which may allow the septum to return to a midline position. An overhanging septal cartilage may also be shortened by minimal resection (2 to 4 mm) of the caudal septum. With severe deformity, extended cartilage removal may require cartilage grafting to avoid loss of nasal tip and dorsal support. While conserving as much cartilage as possible, the surgeon needs to be wary of leaving deformed cartilage in place, which can cause renewed obstruction. Deformed cartilage can be crushed or scored to reduce the likelihood of memory in the cartilage, which can cause poor results. After the cartilaginous structure is fixed, septal flaps are approximated with a horizontal mattress (plicating) absorbable suture. If the field is not completely dry, an incision is made along the ventral aspect of the mucoperichondrial flap, to provide a drainage site to avoid a hematoma. Obviously, if the flap has any tears from the elevation, this step is unnecessary. Silastic septal splints can aid in preventing synechiae, especially when septoplasty has been combined with turbinate resection or endoscopic sinus surgery. The splints are held in place with simple transseptal suture of 5-0 nylon. Splints are by no means, however, essential. The hemitransfixation incision is closed with two mattress sutures of 4-0 chromic catgut. Nasal packing is often used to prevent the postoperative septal hematoma.
Endoscopic Septoplasty
The advent of the nasal endoscope has widened the horizons of otolaryngology. Its value in approaching the sinuses, skull base, orbit, and pterygopalatine fossa is unquestionable. Often during common nasal procedures and during these special occasions, the surgeon’s view is obstructed with narrow access due to septal spurs or septal deviations. These occasions dictate a localized removal of the spurs or the deviation. In these situations, the surgeon may prefer to use the endoscope to assist in localized removal by making an incision just over the spur (Fig. 23.3). The flap is then elevated above and below the spur and the spur is removed (Figs. 23.4 and 23.5). Although the use of endoscope may limit the surgeon’s ability to use both hands during surgery, the advantages of good visualization and magnification surpass its limitation. This technique is limited to localized areas of obstruction due to a spur. The incision usually does not need to be closed.
Figure 23.3 Endoscopic septoplasty: incision is made over the septal spur under endoscopic guidance.
Figure 23.4 Endoscopic septoplasty: mucoperichondrial flaps are elevated above and below the septal spur.
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Revision Septoplasty
The most challenging septal surgery is the revision septoplasty, in which previous surgical resection and scarring alters the surgical plane. In these situations, elevation of the mucoperichondrial flaps is taxing and often results in perforation of the septal flaps.
Figure 23.5 Endoscopic septoplasty: the spur is resected and the flaps are approximated.
Meticulous dissection with a sharp knife and the careful separation of flaps are key in the procedure. Once the flaps are separated, the deflected portion is addressed. Prior to the revision surgery, the surgeon should discern the cause for the persistent deviation. Sometimes it is wise to address the issue of nasal obstruction by performing an endoscope-assisted localized spur removal, as mentioned previously. In cases in which there is persistence of caudal deflection following previous septal surgery, an option may be to widen the area by orbital suspension of the nasal valve (described later in the chapter), instead of elevating septal flaps in an area that is already scarred by previous surgery.
When revision septoplasty is essential, the surgeon should first palpate the septum and outline areas of absent cartilage. The flap elevation should begin in areas where cartilage or bone is present. This may require the use of a nonstandard incision more posterior to the Killian incision. Sometimes the incision may be made over the bony septum. Once flap elevation is accomplished, the prior steps of repair are the same as standard septoplasty.
In combination with septoplasty, nasal fractures can also be reduced. It can be combined with rhinoplasty, which serves as an external compliment. This can be performed either through the intranasal or external route. Rhinoplasty is extensively discussed later in the textbook.
Results
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) performed a nationwide study: Nasal Obstruction Septoplasty Effectiveness (NOSE) study. This was a multicenter study performed in 14 sites, involving 16 investigators from July 2001 through January 31, 2003. Fifty-nine patients underwent nasal surgery. Only 6% of patients reported that they were not pleased by the procedure, and the rest were satisfied with the improvement. This improvement was unchanged at 6 months. Patient satisfaction was very high, and patients used significantly fewer nasal medications (2).
Complications
The major complications following septoplasty are tabulated in Table 23.4. Although complications are rare, they can be very significant. Failure to correct the patients’ symptoms is not considered a complication, and this should be stressed to the patient. Hemorrhage and the potential morbidity associated with control of the bleeding is probably the most common complication. Anosmia is rare but is the most serious permanent complication. Loss of dorsal support and subsequent saddle deformity is a serious cosmetic complication. Septal perforation is always a risk and may cause significant morbidity. Every patient is at risk for all these and the other listed complications.
TABLE 23.4 COMPLICATIONS SEPTOPLASTY
  • Failure to resect adequate cartilage or bone and hence persistent nasal obstruction
  • Hemorrhage
  • Septal hematoma/abscess
  • Synechia
  • Septal perforation
  • Anosmia
  • Excessive resection of dorsal strut can lead to saddle deformity
  • Cerebrospinal fluid fistulas may result from too much traction on the perpendicular plate of ethmoid bone
  • Toxic shock syndrome is possible, particularly if packing is used
  • Rare incidences of aspiration pneumonitis have been reported
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Septal Perforation
Septal perforation usually results when there are bilateral opposing tears in the septal flaps. Septal perforations can be asymptomatic; however, this condition often is associated with crusting and bleeding around the defect and, if the perforation is small, whistling during inspiration or expiration. The turbinate adjacent to the septal perforation can become hypertrophic from an increase in the intensity of nasal turbulence. If the perforation is tolerable and causes no serious detriment to nasal function, management is oriented toward alleviating the symptoms of perforation. Antibiotic ointment can be used to control crusting and bleeding around the perforation. A polymeric silicone button can be used to stop the whistling during inspiration or expiration. These buttons can be shaped to the individual perforation and usually are well tolerated.
Repair of septal perforation limited to defects less than 3 cm in diameter can be accomplished with surgical flaps. With an intranasal approach, septal repair frequently necessitates sliding or rotating mucoperichondrial or periosteal flaps across the defect. Fairbanks et al. (3) have described an advancement flap for the repair. However, large perforations cannot be repaired with advancement flaps.
The use of an inferior turbinate flap for septal perforation repair has been published by our group (4). It essentially involves the freshening of the margins of the perforation (Fig. 23.6), followed by the harvesting of an anterior-based turbinate flap under endoscope guidance. The inferior half of the turbinate actually forms the donor tissue, and the flap includes mucosa, submucosa, and variable amounts of bone depending on the size of the turbinate (Fig. 23.7). The distal portion of the flap is opened to create mucosal surface on one side and submucosal surface on the other side (Fig. 23.8). This flap is sutured to the freshened margins of the perforation (Fig. 23.9). The contralateral side is left open for healing by secondary intention. Three weeks later, the pedicle is taken down, and usually by 3 weeks the contralateral side is also reepithelialized (Fig. 23.10).
Figure 23.6 The septal perforation is rimmed using a no. 12 blade. (From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425–1428, with permission.)
Additional procedures involve bilateral mucosal advancement flaps freed from adjacent septal cartilage or bone, the nasal floor, and the lateral nasal wall. Surgical repair of large perforations is difficult, often necessitating external rhinoplasty or lateral alotomy (incision along the alar cartilage and maxillary crease) for sufficient access to the nasal area. Septal perforation due to nose picking often is easy to close, because of the preservation of health adjacent cartilage, whereas perforation due to overzealous resection of septal cartilage has a dismal
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repair prognosis. Similarly, perforations caused by cocaine use are difficult to repair. In these cases, extensive sections of septal cartilage can be lost, owing to extensive vasoconstriction and irritation of nasal mucosa by cocaine and substances with which it is diluted, such as talc or strychnine.
Figure 23.7 The intended incision site. The anterior attachment of the turbinate is left intact. (From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425–1428, with permission.)
Figure 23.8 The turbinate flap is retracted anteriorly, and the free edge is unfolded to slightly exceed the size of the perforation. (From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425–1428, with permission.)
Figure 23.9 The flap is sutured in place using plain 4-0 catgut. (From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003; 113:1425–1428, with permission.)
Septal Hematoma and Septal Abscess
Septal abscess can follow septal surgery if a septal hematoma is unnoticed during the initial postoperative period. It should be understood that the septal cartilage is avascular and receives its blood supply from the adherent mucoperichondrium. Other causes of septal abscess include blunt trauma, bleeding diathesis, sports injury, and child abuse. Iatrogenic septal hematoma and abscess following nasal septal surgery are probably more common than they are reported. Septal hematoma is characterized by severe localized nasal pain, tenderness on palpation of the nasal tip, and a cherrylike swelling or bluish discoloration of the nasal mucosa emanating from the septum, which obstructs all or a portion of the nasal passage. Septal abscesses generally are larger and more painful than uncomplicated septal hematoma. The overlying nasal mucosa is inflamed and occasionally has inflammatory exudates. Local extension of the infection, if left untreated into the cavernous sinus with subsequent intracranial infection is the most serious potential complication. The most common complication of a septal abscess is cartilage necrosis that results in nasal structural collapse and a saddle-nose deformity.
Technique
Most hematomas and abscesses can be adequately evacuated with topical anesthesia supplemented by local infiltration. Confirm the presence of hematoma by compressing the area with a cotton-tipped applicator. The bulge
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from the hematoma is compressible with the applicator. It should not shrink with the application of a topical vasoconstrictor.
Figure 23.10 The site of pedicle transection (3 weeks after surgery) is denoted by the dotted line. (From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425–1428, with permission.)
As soon as the diagnosis is confirmed, the sutures should be removed and the hematoma should be drained. The clot or the abscess is then evacuated with suction irrigation if needed. A bilateral hematoma can usually be evacuated from one side by gentle pressure to the contralateral side. A ventral incision along one side of the septal mucoperichondrium may help in drainage and may prevent reaccumulation. A wick of 1/8-inch iodoform gauze is inserted through the incision. Care should be taken to ensure that the wick is flat between the mucoperichondrium and the cartilaginous septum. One should not pack the cavity with the wick. This will allow continuous drainage. Apply bilateral nasal packs following the successful drainage of a septal hematoma. Packing inhibits reaccumulation of the hematoma. Proper follow-up is vital to preventing any infectious process or cosmetic deformity. All patients should be reevaluated within 24 hours and again in 48 hours for removal of the nasal packs. These patients will require pain control and broad-spectrum antibiotic coverage.
Turbinate Hypertrophy
Edematous turbinates, whether they are a primary or secondary cause of nasal obstruction, often can be managed by medical or surgical means. Medical treatment targets hypertrophic turbinates that are primarily mucosal in origin. Surgical treatment usually is reserved for structural (bony) abnormalities, or if the mucosal hypertrophy is irreversible with local vasoconstriction. The formation of bony abnormalities may be the long-term result of prolonged hypertrophy of mucosal tissue or the result of traumatic injury to the septum with associated enlargement of the nasal turbinates. Physiologic models of nasal airflow show 50% of inspired airflows along the inferior turbinate or between the middle and inferior turbinates, that is, the middle airway (5). Inferior turbinate hypertrophy that constricts the middle and inferior airways has a marked effect on basal airflow.
Conditions that produce hypertrophy include infectious, allergic, and vasomotor rhinitis. Surgical treatment ranges from lateral repositioning without resection (out fracture) to submucosal resection, removal of redundant mucosa, or both. Inferior turbinectomy frequently is combined with septoplasty to manage contralateral exacerbation of septal deviation. Although inferior turbinectomy is indicated when mucosal hypertrophy is not responsive to medication, resection should be conservative. Morbidity associated with radical inferior turbinate resection includes hemorrhage, ozena, and atrophic rhinitis. The surgeon must weigh the extent of the proposed resection against the nature of nasal obstruction; longer-lasting obstruction may necessitate more extensive resection.
The goals of ideal turbinate reduction surgery are cited in Table 23.5. Unfortunately, there is no single ideal procedure for all patients. Hence, the surgeon has to choose from the array of surgical options that are available and has to select the best procedure to address the pathology in a given patient. The current procedures that are most commonly used to treat bony hypertrophy are (a) submucous resection of the inferior turbinate-classical technique and (b) submucous microdebrider-assisted turbinate reduction. The most common procedure that is now used to treat the mucosal hypertrophy is radiofrequency-assisted turbinate reduction. The other procedures that are less commonly used or that were used in the past are (a) cryotherapy, (b) electrocautery, and (c) laser ablation of the inferior turbinate.
Anesthesia
Most of these procedures can be performed on an outpatient basis unless they are combined with other operative procedures, such as septoplasty, wherein they can be performed in the operating room. In an outpatient setting, the patient is placed in the sitting position. The anterior
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nasal cavity is anesthetized with a topical local anesthetic with epinephrine, and then cotton pledgets with the same solution are placed along the anterior and middle aspects of the inferior turbinate. Transpalatal sphenopalatine ganglion blocks are then performed bilaterally with 1% lidocaine within 1/100,000 epinephrine. After approximately 5 minutes, the anterior aspect of the inferior turbinate is injected with 3 to 5 mL of 1% or 2% lidocaine with epinephrine. The injection provides anesthesia and enlarges the diameter of the turbinate to prevent mucosal injury if radiofrequency is used. It also assists in hydrodissection and elevation of the plane, in cases of submucosal turbinate reduction.
TABLE 23.5 GOALS OF IDEAL TURBINATE REDUCTION
  • Mucosal preservation
  • Controlled reduction
  • Submucous scarring to reduce the erectile nature of the mucosa
  • Bony reduction when necessary
  • Minimal complications
Submucosal Turbinate Reduction: Classical Technique
Conservative submucous turbinate resection, also known as inferior turbinoplasty, has been shown to yield at least 3 to 5 years of relief from mucosal and bony hypertrophy. However, submucosal turbinate resection alone cannot be used to manage nasal obstruction, because of chronic hypertrophy of the nasal mucosa. The physician must address the underlying cause of mucosal hypertrophy to achieve good surgical success.
Submucous resection is performed when the inferior turbinate projects medially and obstructs the nasal cavity or when hypertrophic turbinate mucosa remains unresponsive to vigorous medical management. When performed as an isolated procedure, inferior turbinate resection proceeds after vigorous anesthesia and vasoconstriction of the turbinate and lateral nasal wall. After a posterior to anterior incision is made along the inferior aspect of the inferior turbinate (Fig. 23.11), the mucoperiosteum is elevated off the medial and lateral aspects of the turbinate bone. The turbinate bone is fractured and reduced with Jansen-Middleson rongeur (Fig. 23.12), Takahashi forceps, or turbinate scissors. We prefer the turbinate scissors. The superior and inferior mucoperiosteal flaps are carefully preserved, redundant mucosa is trimmed from the inferior mucoperiosteal flap, and the superior mucoperiosteal flap is placed laterally over the resected inferior turbinate. The mucoperiosteal flap is gently packed in place for 24 to 48 hours with antibiotic impregnated petrolatum gauze, to ensure proper adhesion and healing of the mucoperiosteum to the resected turbinate bone. An alternative is to place horizontal (plicating) mattress sutures through a minimally resected turbinate, to obviate uncomfortable nasal packing.
Figure 23.11 Limit incision to anterior two-thirds of turbinate bone.
Figure 23.12 Cottle elevator used to elevate mucoperiosteum from medial, lateral, and inferior surfaces of turbinate.
Submucosal Microdebrider-Assisted Turbinate Reduction
Most of the techniques described involve treatment of submucous tissue with sacrifice of mucosa for access to the target area. Techniques such as partial or total inferior turbinectomy, cryosurgery, electrocautery, and laser destroy the mucosa, thereby interfering with nasal physiology. Classic submucous resection of the inferior turbinates is a technique designed to preserve the mucosa, but it is a misnomer because the resection includes some mucosa. The main goal of this type of surgery should be the preservation of mucosal surfaces, with reduction of the submucosal and bony tissue. Powered instrumentation used in a functional approach to inferior turbinates offers advantages over traditional techniques with regard to complications and mucosal preservation. In addition, resection with classical technique can often result in overcorrection and possible atrophic rhinitis.
An incision is made with a no. 15 blade in a vertical manner, in the anterior aspect of the inferior turbinate. A submucosal pocket is created with sharp dissection on the medial surface of the bony turbinate. The straight microdebrider (4-mm tip with tricut blade) is applied through the incision. Alternatively, a specially designed turbinate microdebrider blade is available from Medtronics (Minneapolis, MN). It includes a knife for sharp elevation and a 3-mm blade for turbinate reduction. The bony turbinate and some of the submucosal tissue is debrided at
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5,000-cps oscillating mode in a ventrocaudal manner. Debridement should be performed with the blade positioned laterally from the submucosal plane. The 6,000-cps forward mode is used when the bony turbinate is hard to debride. Particular attention should be paid to preserve the mucosal flap. Hemostasis can be achieved under direct vision with suction electrocautery, when necessary. The incision need not be closed. The reduction in size of the inferior turbinate is usually recognized immediately after the procedure. This technique allows for incremental controlled submucosal turbinate reduction. Light nasal packing is helpful for 24 hours, to avoid postoperative bleeding. As in any procedure, the technique requires a learning curve, to know how much of the tissue or the bone can be resected to achieve an effective airway, without leading to complications such as atrophic rhinitis.
Results of Microdebrider-Assisted Turbinate Reduction
Studies conducted by the senior author indicate that out of 120 patients who underwent this technique, 75% had complete resolution of their symptoms of nasal obstruction, and the rest had some resolution of their symptoms (complained of minimal nasal obstruction postoperatively). Synechiae occurred in 5% of the patients. None of the patients studied suffered crusting, foul odor, or nasolacrimal duct injury complications (6).
Radiofrequency-Assisted Turbinate Reduction
The recent advance of radiofrequency energy has given further advantage for otolaryngologists in the reduction of turbinate hypertrophy. Temperature-controlled radiofrequency delivers a current of 460 kHz, by a high-frequency alternating current flow into the tissue, creating ionic agitation. This ionic agitation heats the tissue, and as the temperature rises higher than 47°C, protein coagulation and tissue necrosis ensue. Collagen deposition begins approximately 12 days after injury, and at 3 weeks, chronic inflammation, fibrosis, and tissue volume reduction from scar contracture occur. This can be performed either by using unipolar or bipolar radiofrequency probes that can be delivered to the anterior, and if required, to the middle aspects of the inferior turbinate. Approximately 300 to 550 J of energy is delivered, and after the probe is removed, a cotton pledget with oxymetazoline is placed along the anterior turbinate for hemostasis. Some advocate a bipolar probe as better in terms of instant tissue reduction, but no study has clearly shown that one technique is superior.
Results of Radiofrequency-Assisted Turbinate Reduction
The posttreatment findings after inferior turbinate radiofrequency include nasal swelling for 24 to 72 hours. Final reduction is complete in 3 to 4 weeks, and retreatment can be performed if nasal obstruction persists. Bleeding, crusting, dryness, adhesions, and infection are rare complications. The advantage of this procedure is that it is less time-consuming and more efficient than other historical procedures for chronic mucosal hypertrophy, such as cryotherapy, electrocautery, and laser ablation. It does not require nasal packing, which is an advantage over submucosal microdebrider reduction.
Carbon dioxide laser vaporization of the turbinate had previously been accepted as a common treatment for allergic rhinitis. Usually, only a single procedure is applied to minimize trauma. However, repeated procedures on separate days are often required to achieve an adequate effect. Holmium (Ho): Yttrium aluminum garnet (YAG) laser treatment is used in the turbinate reduction and is efficacious, but has poor long-term efficacy (7). Potassium-titanyl-phosphate (KTP/532) laser, a useful tool in endoscopic intranasal operations, has been investigated in endoscopic inferior turbinate reduction and appears to be an alternative in the management of turbinate hypertrophy. Although it achieves better results in controlling nasal obstruction, the results are less promising in treating postnasal drip and rhinorrhea (8). Further, many of these laser techniques ablate the mucosa, whereas ideally one would always want to preserve the mucosa to preserve the mucociliary function.
Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal mucociliary functions was performed by Sapci et al. (9). They found that at 12 weeks after surgery, the nasal mucociliary transport time was 25.60 minutes on the side where laser ablation was applied and 11.40 minutes on the side where partial turbinectomy was applied. In the patients on whom radiofrequency tissue ablation and partial turbinectomy were applied, the average nasal mucociliary transport time was 10.33 minutes on the radiofrequency tissue ablation side, whereas it was 11.33 minutes on the partial turbinectomy side. They concluded that radiofrequency tissue ablation to the turbinate is effective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary function significantly. With the partial turbinectomy technique, results obtained were similar to the results with the radiofrequency tissue ablation technique.
Ablative turbinate surgery, such as radiofrequency and laser ablation, is used only to reduce obstructive hypertrophic nasal mucosa. Used alone, these procedures reduce nasal obstruction due to mucosal hypertrophy but not anatomic deviation. After turbinate ablation, if the source of nasal irritation and mucosal hypertrophy is not eliminated, such as removal of sources of dust or mold allergy or alteration of diet to exclude suspected allergens, the physician should anticipate a recurrence of mucosal hypertrophy.
Nasal Valve Obstruction
The nasal valve is the narrowest portion of the nose. When insufficient cartilaginous support is present, negative
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(inspiratory) pressure within the nasal cavity can collapse soft tissue in this region. Nasal valve collapse is a common cause of nasal airway obstruction. The valve area is commonly weakened secondary to rhinoplasty, aging, trauma, and other causes. Fixed valve obstruction may be secondary to trauma, scarring, previous rhinoplasty, or a narrow valve area secondary to persistent caudal septal deviation.
TABLE 23.6 EMERGENCIES NASAL OBSTRUCTION
Diagnosis Emergency Complications
Septal hematoma Elevation of mucosal perichondrium with cartilage devascularization Septal cartilage necrosis, development of a saddle-nose deformity
Septal abscess Intracranial extension of infection Septal cartilage necrosis, development of a saddle-nose deformity, cavernous sinus thrombosis, intracranial infection
Mucormycosis Tissue destruction Extension to brain or orbit
Surgical reconstruction of an incompetent nasal valve can be undertaken with an open approach that allows clear assessment of operative augmentations. The most successful operative techniques include systematic alteration of all surrounding valve spreader cartilage grafts (widening the apex if the internal valve); suture repair of the drooping upper lateral cartilage (a frequent complication after dorsal hump excision in rhinoplasty), autogenous cartilage grafts, or allografts as needed to support the columella; and spanning grafts or simple lateral crus onlay grafts to support the lateral crura (10). Grafts can be composed of cartilage or conchal bone from concurrent inferior turbinectomy. The bony or cartilaginous graft serves as both an inherent structural support and a method for inducing site-specific scarring, which enhances the stiffness of this region. The results of these techniques are quite variable and depend on the surgeon’s experience. The complications of open procedure range from hematoma to graft rejection (Table 23.6). Most of these complications are similar to open rhinoplasty. Please refer to the chapter on rhinoplasty for avoidance and management of these complications.
The complexity of nasal valve repair techniques and its variable results, combined with the fact that patients with valve obstruction have often had previous surgery or are of advanced age, are some of the reasons that this problem often goes untreated. Paniello (11) published a preliminary report on 12 patients in which a simplified technique for nasal valve repair was used that involved suspension of the valve to the orbital rim.
The author (M.F.) modified his technique, which is simpler, safer, and equally effective. It is based on the use of a soft tissue bone anchor system that provides a simplified support of the valve area to the orbital rim, and the author has published data on 240 patients who have undergone the revised procedure (12,13). The procedure can be performed under local anesthesia (office-based), or with general anesthesia if combined with other surgical procedures.
Surgical Technique
The nasal valve area is examined prior to injection of local anesthesia to avoid distortion of tissue. Two points representing the caudal and cephalad margins of the collapsed area are marked. An incision is made through the mucosa connecting the two points (Fig. 23.13). A natural skin crease along the orbital
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rim is marked (Fig. 23.14). We have used an external incision in almost every patient, with no significant scarring. The incision is so small, and its placement within a natural skin crease makes the external incision the recommended choice. Local anesthesia with epinephrine is then injected into the valve area, along the maxilla, near the infraorbital nerve, along the orbital rim. A 3-mm incision is made in the medial aspect of the orbital rim. The skin incision is through skin only, orbicularis oculi muscle fibers are pushed, and periosteum is incised and elevated. Rarely is bleeding encountered, but if it is, bipolar cautery is used to control it. The periosteum is elevated away from the orbital rim to expose a 3 × 3 mm area. The Mitek soft tissue anchor system (1.3 mm Micro Quick Anchor, Ethicon, Inc., Piscataway, NJ), which includes the drill bit, bone anchor, and attached suture, is used to anchor a suture to the orbital rim. A small drill hole is made into the bone (Cordless Driver 2, Stryker Corporation, Kalamazoo, MI) and the Mitek anchor is then easily inserted into the bone (Fig. 23.15). The longer end of the suture is then passed with a curved needle (Richard-Allan 1/2-inch, curved, tapered needle) to the nasal valve area and passed through the cephalic point. It is important to place the hole medial and high at the orbital rim where the bone is thick enough so that the anchor does not enter the sinus. The needle pass should be as close to the maxillary bone as possible and not in the soft tissue of the face. The incision that was made initially connecting the two points buries the suture. After identifying the collapse site and the intended site of suspension, the needle is then rethreaded and passed from the caudal point toward the anchor (Fig. 23.16). The suture is then tightened and tied with the proper amount of tension to open the valve but to avoid significant distortion of the external valve area (Figs. 23.17 and 23.18). Occasionally, two bone anchors and four points of fixation are needed for adequate correction.
Figure 23.13 Intranasal incision connecting the two sides of suspension to allow for subcutaneous/submucosal placement of suture. The incision was not closed. (From Friedman M, Ibrahim H, Lee G, Joseph NJ. A simplified technique for airway correction at the nasal valve area. Otolaryngol Head Neck Surg 2004;131:519–524, with permission.)
Figure 23.14 Incision site: 3 mm placed in skin crease. (From Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 2003;113:381–385, with permission.)
Figure 23.15 Medial to the intraorbital nerve and slightly below infraorbital rim, the anchor is drilled. (From Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 2003;113:381–385, with permission.)
Complications
The most common complication following the procedure is the foreign body reaction to the Mitek anchor system. Sometimes, abscesses can form over the incision site. This requires aspiration of the abscess, which should be subjected to culture and sensitivity and treated with the appropriate antibiotic. In other cases, granuloma formation has been known to occur. In 5% of these patients, suture removal is required. Other, less common complications include hematoma following injury to the angular vein during placement of the anchor into the maxillary sinus (Table 23.6).
Results
Our experience with the orbital suspension technique was from 2001 to 2004. All patients had minor changes in their external appearance that were either considered an improvement or inconsequential. Nearly all patients (91.7%) had significantly improved airways in a short-term study. The only complication reported was the foreign body reaction following the procedure that eventually required removal. Long-term results are not available (13).
Choanal Atresia
Choanal atresia is a genetic disorder in which the posterior choanae unilaterally or bilaterally fail to develop properly. It occurs in 1 in 5,000 births; choanal atresia is more
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common among girls (2:1), and unilateral atresia is more common than bilateral atresia. This disorder can be transmitted as an autosomal recessive trait (14). Because newborns are obligate nose breathers, bilateral atresia is immediately apparent as respiratory distress. An endotracheal tube is inserted, and the infant is examined. Characteristics in the history that are found at failure to pass a rubber catheter or nasogastric tube into the pharynx can provide enough information for a diagnosis. Symptoms of choanal atresia include failure to thrive due to poor feeding and mucoid discharge from the affected side. The presence of choanal atresia can be confirmed with visualization of retention material in the posterior part of the nose on a lateral radiograph with the patient in the supine position. Anatomic characterization of the deformity with CT scanning can be important for planning surgical procedures.
Figure 23.16 After identifying the collapse site and the intended sites of the suture suspension, the curved needle is passed through the incision and the subcutaneous tissue into the nose. (From Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 2003;113:381–385, with permission.)
Figure 23.17 Prior to tying the suture, the nasal valve is shown in its collapsed position. (From Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 2003;113:381–385, with permission).
Figure 23.18 The suspension suture after tying and prior to skin closure. (From Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 2003;113:381–385, with permission.)
In the care of an infant, surgical methods for membranous atresia include puncture of the choanal membrane and placement of a stent for 6 weeks. If the bony atresia is present, the bony wall can be taken down transnasally with microsurgical or endoscopic techniques followed by placement of a stent. When suboptimal resection for atresia of choanal stenosis occurs, transpalatal repair at 3 or 4 years of age is advised.
Unilateral atresia can go unrecognized until adulthood, at which time the patient seeks medical attention because of possible septal deviation. The septum usually deviates to the affected side; however, more posterior examination shows atresia. Computed tomographic scans of this region provide enough information for the diagnosis. Transpalatal repair is being replaced by endoscopic techniques of repair of atresia in children and adults (15).
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References
1. Vidyasagar R, Friedman M, Ibrahim H, et al. Inspiratory and fixed nasal valve collapse: clinical and rhinometric assessment. Am J Rhinol 2005;19:370–374.
2. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg 2004;130: 283–290.
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10. Teichgraeber JF, Wainright DJ. The treatment of nasal valve obstruction. Plast Reconstr Surg 1994;93:1174–1182.
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13. Friedman M, Ibrahim H, Lee G, Joseph NJ. A simplified technique for airway correction at the nasal valve area. Otolaryngol Head Neck Surg 2004;131:519–524.
14. Gershoni-Baruch R. Choanal atresia: evidence for autosomal recessive inheritance. Am J Med Genet 1992;44:754–756.
15. Josephson GD, Vickery CL, Giles WC, et al. Transnasal endoscopic repair of congenital choanal atresia. Arch Otolaryngol Head Neck Surg 1998;124:537–540.