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Shamsiev Djakhongir Fazlitdinovich, Tashkent State Dental Institute Ibatov Nodir Abdullaevich, Tashkent State Dental Institute E-mail: dr_ulugbek@list.ru
REASONS OF FUNCTIONAL DISTURBANCES AFTER RHINOPLASTIC DEPENDENCE ON SURGICAL ACCESS, TECHNOLOGY AND VOLUME OF OPERATION
Abstract: The aim of this research was to study the reasons of functional disturbances after rhinoplastic dependence on surgical access, technology and volume of operation. We were operated 54 patients with deformity of the skeleton of the external nose in the period from 2015 to 2017. Open osteotomy was applied in 38 patients who needed correction of both the bone and cartilage sections of the external nose. In closed osteotomy (16 patients), we used lateral vestibular access. The study showed that to achieve a good result after endonasal intervention on the intranasal structures in combination with rhinoplasty, an important fact is the adequate management of patients in the postoperative period, with careful carrying out the necessary therapeutic and preventive measures.
Keywords: rhinoplasty, surgical access, septoplasty, closed osteotomy, mucous membrane.
Recently, many have shown interest in rhinoplastic op- assess the dynamics of the disease after the operation, we used erations, while at the same time trying to eliminate the de- the method of visual assessment of symptoms. To do this, pa-
formity of the external nose and do not pay attention to the preservation or restoration of the functions of the nasal cavity and paranasal sinuses. It must be borne in mind that when performing rhinoplasty, in addition to cosmetic tasks, it is also necessary to solve more complicated task - restoration of the functions of the nasal cavity. Therefore, aesthetic operations in the area of the external nose should be performed by otorhinolaryngologists, who also have endonasal surgical procedures [1; 3; 6].
Abroad in many countries, this situation has been corrected, and now, for example, in the United States, about 85% of rhinoplasty is performed by otorhinolaryngologists, who simultaneously perform intranasal operations to restore respiratory function and restore the shape of the nose [2].
Starting to master rhinoseptoplasty, the surgeon should master the skills of several related specialties: plastic surgery, maxillofacial surgery, thoroughly study the anatomy of both the bone and cartilage sections of the pyramid of the nose, know the features of reparative processes in the bone, cartilage tissue, skin and subcutaneous tissue. It is simply impossible to do rhinoseptoplasty badly, since repeated operations will be much more complicated [4].
Under our supervision there were 68 patients who underwent rhinoplasty. When comparing the results of the examination of patients operated on with various surgical approaches, it turned out that nasal breathing disorders were significantly more frequent after the "endonasal" technique (65%) than after the "open" rhinoplasty (48%) [5].
We have found the connection of functional disorders after rhinoplasty with the volume of the operation. In order to
tients before the operation were offered to fill in special cards in which they noted the severity of the main symptoms (nasal breathing, nasal discharge, headache) on a 10-point scale.
When comparing patients in whom one-stage with rhi-noplasty was performed various intranasal interventions (conchoplasty, septoplasty) and patients who had exclusively rhinoplasty, the functional result of the intervention was significantly better in the first group (5.3 ± 1.5 points and 9.2 ± ± 1.3 according to the subjective assessment of patients, respectively).
A significant proportion of patients (71%) who have undergone aesthetic rhinoplasty have a significant impairment of nasal breathing. The main causes of postoperative nasal obstruction are insufficiency of the nasal valve (65%), curvature of the nasal septum (61%), hypertrophy of the lower nasal concha (35%), synechia of the nasal cavity (8%), bulls of the middle nasal conchae (4%).
Unlike the function of nasal breathing, the state of mucociliary transport in patients undergoing rhinoplasty does not significantly suffer (the time of mucociliary transport is 17 ± 2.8 versus 16 ± 2.9 (p > 0.05). Signs of impaired sense of smell have been detected in some patients only early postoperative period.
In 60% of patients undergoing aesthetic rhinoplasty, is detected a violation of local innervation in the form of hy-poesthesia. With the course of the postoperative period, the severity of neuralgic disorders decreases, but in 3% it persists with long-term follow-up. The most significant changes are observed in patients after open access, resection of the base of the wings and lateral endonasal osteotomy.
Nasal breathing disorders are significantly more common after endo-nasal surgical access (55%) than after open rhinoplasty (48%). In a one-step rhinoplasty and intranasal intervention (conchoplasty, septoplasty), the functional result of the intervention is significantly better (5.8 ± 1.5 points versus 8.9 ± 1.3 by subjective assessment.
Functional impairment after rhinoplasty is usually associated with the size of the operation. When comparing patients in whom one-stage with rhinoplasty was performed various intranasal interventions (conchoplasty, septoplasty) and patients who had exclusively rhinoplasty, the functional result of the intervention was significantly better in the first group (6.2 ± 1.5 points versus 8.9 ± 1.3 by subjective assessment.
The main types of osteotomy are: lateral, medial, and paramedial. Depending on the tasks of the operation and the features of the structure of the bone pyramid of the nose, we use all these types of osteotomies, often combined. For better mobilization of the nasal bones before performing the lateral we carry out a medial oblique or paramedial osteotomy. We do not connect the lines of the medial and lateral osteotomies, trying to break the bone bridge in the "green line" type.
In principle, there are two methods for performing osteotomy - open and closed. We were operated 54 patients with deformity of the skeleton of the external nose in the period from 2015 to 2017. Open osteotomy was applied by us in 38 patients who needed correction ofboth the bone and cartilage sections of the external nose. The advantages of the open technique are that the access to the structures of the nasal dorsum is maximal and the manipulations are performed under visual control. Another distinctive feature of open osteotomy is the possibility of controlled displacement of the bones of the nose with respect to the nasal septum and the correction of the latter, if necessary, without additional incisions.
In closed osteotomy (16 patients), we used lateral vestibular access. Traditionally, we performed an osteotomy with special chisels (2 mm) with stops, starting from the edge of the pear-shaped hole below the anterior end of the lower turbinate. In this case, the likelihood of damage to the nasal mucosa along the osteotomy line is minimal. When using 4 mm bits, the risk of intraoperative complications is markedly increased. So, 2 patients had damage to the nasal mucosa (which led to a slight narrowing of the anterior valve of the nose in one of them), in 1 - a step-like deformation of the nasal pyramid.
A good cosmetic result was achieved in 50 patients. We believe that in patients with distortions of the osseous part of the external nose, closed osteotomy should be dominated by lateral vestibular access, open osteotomies are indicated with combined pyramid deformations.
The main stages of the postoperative period. The final stage of rhinocorrection is the closure of the operative wound,
immobilization and fixation of the intra- and extranasal structures. Stitching the wound was performed with frequent and accurate absorbable sutures, with careful adaptation of the edges. After precise suturing, there remains a thin scar that does not deform the skin and mucous membrane, the external valve structure of the nose in the postoperative period. After suturing, intranasal structures were fixed. Fixation of the nasal septum in a strictly medial position and hemostasis were achieved by installing plastic tubes of appropriate diameter and length along the bottom of the nasal cavity with a non-lengthening tamponade with special hydrophilic spongy tampons made from self-expanding oxycellulose. Such a tamponade is more easily tolerated by patients, protects the wound from infection, contributes, due to light pressure exerted from the nasal cavity, gluing tissues, reduces the possibility of hemorrhages and hematomas, keeps the reconstructed structures in the right position. The presence of plastic tubes, in addition to fixation, provides air through the nose, protecting the oropharynx from excessive drying. After all corrective manipulations, a plastering bandage is applied to fix the skin on the reconstructed pyramid of the nose. Immobilization of extranasal structures was carried out by applying a plaster cast, modeling it so that it covered the entire nose from its root to the tip and wings, and it should be smooth from the inside and exert a uniform slight pressure on the nose. Analysis of the data of the observed patients and clinical experience revealed that the postoperative course after single-stage rhino-plasty and endonasal correction of the intranasal structures has important criteria and features that need to be discussed in more detail. Immediately after surgery, the period of recovery of the epithelium of the nasal cavity begins. This stage is crucial for the complete healing of defects of the mucous membrane, affects the results of endonasal intervention, and therefore requires close attention in the postoperative period. Inadequate management of patients in the postoperative period can cause new pathological changes in the nasal cavity, which can cause relapses that are worse to treat than the primary disease. As noted, immediately after the operation, a tampon of self-expanding cellulose is inserted into the middle nasal passage. At the same time, it is necessary, if possible, to separate all contiguous de-epithelized wounded surfaces - the septum and the middle shell, or the middle shell and the lateral wall of the nose. Minor bleeding in the postoperative period, especially after removal of tampons on the third or fourth day after the operation, leads to the formation of blood clots in the nasal cavity, which then dry out, forming massive scabs. Due to the lack of mucociliary clearance, mucous secretions from the open sinus dry out and form yellow-brown crusts that adhere to existing defects of the mucous membrane. Then, in the following days, granulations are formed at the
sites of these defects. Most of the sero-mucous wound discharge accumulates at the bottom of the nasal cavity and in the paranasal sinuses. On the mucous membrane of the nasal concha, fibrinous deposits are often formed, significantly complicating nasal breathing. Until the mucociliary system begins to function adequately, the secretions of the respiratory epithelium will dry out and form crusts. Even small damage to the epithelium can lead to bleeding with the formation in the postoperative period of adhesions between the mucous membranes. After a few days there are sometimes quite extensive swelling. They are due to impaired lymphatic drainage and can last up to 4 weeks after the intervention. The edema of the mucous membrane, to a greater degree, is expressed in the region of the lower and anterior edges of the newly formed or expanded anastomosis in the middle nasal passage, may be similar to small polyps. In narrow places, edema can even cause occlusion of the anastomosis, accompanied by pain. X-ray examination to determine the tactics of further treatment, at this stage of the postoperative period, is impractical, since the inflamed edematous mucosa of the paranasal sinuses will darken the X-ray, and can lead to incorrect hyperdiagnostic conclusions. According to many authors, and based on clinical experience, the final results and the effectiveness of endonasal intervention should be more correctly based on the CT data of the study, moreover, carried out not earlier than 2-3 months after the intervention. Within a week after the intervention should be performed a thorough toilet of the nasal cavity; only lumps and mucus from the vestibule, the bottom of the nose and the middle nasal passage should be carefully removed. For this purpose, a straight metal suction is used, allowing the finger to precisely control the force of aspiration. Damage to the mucosa should be avoided by coarse insertion of the suction tip or aspiration from areas of the loose mucosa. To remove exudates dried in the form of crusts, scabs or fibrinous plaque, cranked or bayonet-shaped tweezers are suitable. Already at this stage, it is recommended to carry out postoperative therapy under endoscopic control. The use of endoscopy helps prevent injury to the regenerating parietal mucosa, effective cleaning is provided by gentle aspiration, and a small retractor or exciting forceps are suitable for removing large patches of crusts and crusts. Care should be taken to avoid additional damage to the epithelium, since bleeding from the mucous membrane is the result of too rough manipulation. During the first week after surgery, the restoration of the epithelium is just beginning. During this period, all emerging cicatricial adhesions in the nasal cavity should be removed, sucking the contents and removing crusts and deposits. Particular attention should be paid to the formation of adhesions between the de-epithelized areas of the mucous membrane, namely, the middle turbinate and the nasal septum, the middle turbinate,
and the lateral wall of the nose. It is here that the contiguous wound surfaces are often glued to each other by fibrin bridges, which within 10-12 days turn into fibrin cicatricial synechia. In many cases, these synechias lead to obstruction of even, sufficient in size, fistula of the maxillary sinus and, ultimately, to a violation of the outflow from the frontal and ethmoid sinuses. This leads to accumulation of secretions in these cavities. In addition, a pronounced narrowing of the labyrinth of the ethmoid bone leads to partial or complete cicatricial obliteration, fibrin bridges from these areas should be carefully removed by suction or cross them. After gentle removal of crusts and blobs and suction of secretions, to accelerate the recovery of the epithelium, and in order to facilitate the cleaning process, it is recommended that the nasal cavity be moistened with saline or isotonic saline. In special cases, it is recommended to use low viscosity ointments, gels or drops containing antibiotics and corticosteroids. All this helps cleanse and heal the wound, destroying the fibrin layer and clotted blood, and also has an anti-inflammatory effect on the edematous mucosa. Instilling a saline solution into the nose or using a nasal spray from an isotonic sea salt solution prevents the secretions from drying out and dissolves adhesions between the surfaces covered with mucous membrane, increases the level of secretion in the goblet cells, thus stimulating mucociliary clearance. After the early postoperative stage, which lasts approximately two weeks, there is a late postoperative period. Hyperplasia and granulation of the mucous membrane gradually begin to decrease, but the swelling may persist for several weeks or months. Mucociliary clearance, which is known to be a criterion for restoring the function of the mucous membrane of the nasal cavity and paranasal sinuses, usually returns to normal only 2-4 months after surgery. In the late postoperative period, granulations, tissue proliferation and sometimes small polyps can occur. In addition, again may increase mucosal edema. Regular implementation of the endonasal examination and the toilet allows you to timely detect such changes and monitor the condition of the nasal cavity and lumen of fistulas. One of the main late complications is the formation of cicatricial adhesions between the middle shell and the lateral wall of the nose. To prevent the formation of pronounced synechia on the front of the middle turbinate, it is necessary to clean the fibrin strands, and when synechia are formed, it is enough to excise the scars with a nasal scissors or an appropriate scalpel. In order to avoid recurrence of the formation of synechiae, it is necessary to periodically insert within 8-10 days small fragments of tampons from self-expanding hydroxycellulose between the contacting wounded surfaces. In the late postoperative period, you need to continue drug therapy. To moisten the mucous membrane, the patient is recommended to
regularly instill into the nose a saline solution, an isotonic solution of sea water. In addition to the moisturizing effect, this type of irrigation allows you to effectively clean the mucous membrane. According to the authors, the ionic concentrations of sea salt solutions enhance the function of cilia, which improves mucociliary clearance. At this stage of treatment, as an adjuvant therapy, you can regularly irrigate the nasal mucosa with oil drops, olive or sesame oil. After endonasal interventions, swelling of the mucous membrane can last for several weeks. The epithelium covering the wound sites is initially thickened and has an uneven, undulating surface. The epithelium is very easily damaged during the recovery phase, so any unnecessary manipulations should be avoided. A staged endoscopic examination of the nasal cavity, as well as through the extended fistula, and the operated sinus, revealed that only a few months after the intervention, the wound surfaces completely epithelialized, and the nasal mucosa and paranasal sinuses acquire a smooth surface. The ciliated epithelium, however, is not represented everywhere, since some areas are covered by stratified squamous epithelium. However, in this period, there is no longer any risk of restenosis of fistulae or the formation of synechias and obliterations. Maintaining patients after single-stage rhinoplasty and correction of the intranasal structures in relation to the pyramid of the external nose, also has important steps and features. The plaster cast is removed on the 7th day after the intervention. Then a re-ban-
dage was applied, if necessary, also a plaster bandage. Postoperative puffiness and thickening of the nasal tissues decrease and disappear by the end of 2-3 weeks and depend on the volume of surgical intervention and rehabilitation capabilities of the body. Hypersensitivity and soreness to pressure decreased by the 4th week after the operation, the tightening of the nasal tissues was observed within 2-3 months. After the disappearance of pain, if necessary, in order to restore the mobility of the skin and the prevention of coarse subcutaneous scarring, a gentle massage, often performed by the patient himself, was recommended.
Thus, to achieve a good result after endonasal intervention on the intranasal structures in combination with rhinoplasty, an important fact is the adequate management of patients in the postoperative period, with careful carrying out the necessary therapeutic and preventive measures. It should be noted that in the preoperative period, at the planning stage of the intervention and discussion with the patient of the plan and algorithm of surgical treatment, it is necessary to inform the patient in detail about the main stages of the postoperative period, the phases of postoperative wound healing, and his health during this period. Full mutual understanding and agreement between the patient and the operating surgeon will make it possible to successfully complete the difficult stage of the postoperative period and overcome all the difficulties of rehabilitation.
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