Background: Rhinoplasty is one of the most common aesthetic procedures. It has several potential complications. There is no systematic study with direct focus on these complications.Purpose: To evaluate the likelihood for occurrence of different complications following septorhinoplasty.Methods: One hundred and fifteen patients who underwent rhinoplasty were observed for post-operative occurrence of nasal obstruction, hyponasal speech, Post Nasal Discharge (PND), rhinorrhea, facial congestion and headache. They were also examined for aesthetic results of the surgery and asked about their satisfaction about the external shape of the nose as well as overall satisfaction of surgery.Results: Twenty-one patients developed sinonasal symptoms after surgery.The most annoying symptom was permanent unilateral nasal obstruction which was observed in 38% of patients followed by long lasting PND (19%), anosmia (14%) and altered voice resonance (9%). Five patients eventually underwent surgery due to their functional problems.Conclusion: Rhinoplasty and septorhinoplasty have numerous complications. Nasal obstruction, PND and anosmia are the most common. A careful follow-up is required for diagnosis and appropriate treatment of these complications

Abbaszadeh, Hojjat-allah

Ahmady Roozbahany, Navid

Asadi, Shahab

English

Journals Portal, Shahid Beheshti University of Medical Sciences

ORIGINAL ARTICLEJournal of Hearing Sciences and Otolaryngology. 2015;1(1):9-12©2015 Publisher: Hearing Disorders Research Center, Shahid Beheshti University of Medical Sciences. All rights Reserved.Post-rhinoplasty Sinonasal SymptomsNavid Ahmady Roozbahany1, Shahab Asadi1, Hojjat-Allah Abbaszadeh21-Hearing Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran2- Department of Biology and Anatomical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IranCorresponding Author : Navid Ahmady Roozbahany, MD, Hearing Disorders Research Center, Shahid BeheshtiUniversity of Medical Sciences, Tehran, Iran; Email: s.asadi@sbmu.ac.irABSTRACTBackground: Rhinoplasty is one of the most common aesthetic procedures. It has several potential complications.There is no systematic study with direct focus on these complications.Purpose: To evaluate the likelihood for occurrence of different complications following septorhinoplasty.Methods: One hundred and fifteen patients who underwent rhinoplasty were observed for post-operativeoccurrence of nasal obstruction, hyponasal speech, post nasal discharge (PND), rhinorrhea, facial congestion andheadache. They were also examined for aesthetic results of the surgery and asked about their satisfaction about theexternal shape of the nose as well as overall satisfaction of surgery.Results: Twenty-one patients developed sinonasal symptoms after surgery. The most annoying symptom waspermanent unilateral nasal obstruction, which was observed in 38% of patients followed by long lasting PND(19%), anosmia (14%) and altered voice resonance (9%). Five patients eventually underwent surgery due to theirfunctional problems.Conclusion: Rhinoplasty and septorhinoplasty have numerous complications. Nasal obstruction, PND andanosmia are the most common. A careful follow-up is required for diagnosis and appropriate treatment of thesecomplications.Keywords: Rhinoplasty; Post-operative Symptoms.Please cite as: Ahmady Roozbahany N, Asadi S, Abbaszadeh H, Post-rhinoplasty sinonasal symptoms. Journal ofHearing Sciences and Otolaryngology 2015; 1(1):9-12.INTRODUCTIONRhinoplasty is one of the most common nasalprocedures. It is often performed in conjunctionwith septoplasty (1). Theoretically, nasal airwayand sinonasal function should not be altered duringrhinoplasty or it should get better. In reality, thereare numerous post-rhinoplasty patients with newor sustained sinonasal symptoms.In a number of patients, the symptoms initiatedafter surgery and in others, the pre-operativesymptoms were not completely recovered or eventhey have become worse post-operatively (2).Even though this issue seems to be very frequentand can potentially imposes a considerablydifficult situation both for the patient and thesurgeon, it has not been reviewed and there wasnot enough studies to find out the right prevalenceof postrhinoplasty sinonasal symptoms.PATIENTS and METHODSPatients who underwent rhinoplasty orseptorhinoplasty included in this retrospectivestudy. Patients who had complaint of nasalobstruction, congestion, hyponasal voice,continuous post nasal discharge (PND),continuous rhinorrhea and history of rhinitiswere excluded from study. The patients whowere diagnosed with polyposis, chronicrhinosinusitis (CRS) or rhinogenic contact pointheadache (RCPH) were also excluded from thisstudy. At the end, one the hundred and fifteenpatients were enrolled in the present study. Theywere informed about the conditions and methodsof the study and written consent were obtainedfrom participant. All patients underwentrhinoplasty using open approach. Depending onthe condition, standard techniques were used toaddress each patient’s problem. Cartilaginousgrafts for reconstruction of internal valve(spreader grafts), external valve (alar cartilagestrut) or columella were used when it wasnecessary. No obvious septal deviation leftuntreated. The patients were followed up for atleast 6 months and then underwent physicalexamination and they were asked to fill aquestioner regarding their sinonasal symptoms.We investigated post-operative occurrence ofnasal obstruction, hyponasal speech, PND,rhinorrhea, facial congestion and headache.OPEN ACCESSAhmady Roozbahany N. et al.10©2015 Publisher: Hearing Disorders Research Center, Shahid Beheshti University of Medical Sciences. All rights Reserved.They were also examined for the aestheticresults of the surgery and they were asked abouttheir satisfaction about the external shape of thenose as well as overall satisfaction of surgery.The data was analyzed by SPSS v. 19 forwindows.RESULTSOne hundred and fifteen patients underwentrhinoplasty or septorhinoplasty from which 76(66.1%) were female and 39 (33.9%) were male.The mean age was 27.2 ± 5.2. Overt septaldeviation was present in 89 cases (77.4%).Hump removal and lateral osteotomy performedin all patients. Spreader graft inserted in 45(39.1%), lateral crural strut graft in 12 (10.4%),Gunter’s graft in 8 (6.6%) and columellar strutgraft in 102 (88.7%) patients.The patients were followed up for at least 6months (12.4±6.1). One hundred and one cases(87.8%) were satisfied with the external nasalappearance. The remaining had some complaintsabout the aesthetic issues, which led to revisionsurgery in 7 patients (6.1%).On the functional point of view, 21 patientsdeveloped sinonasal symptoms after surgery.There were 12 patients (10.4%) with minorsymptoms namely sensation of alternating nasalblockage especially during nighttime and senseof abnormal cooling of the nasal tip. On theother hand, in 9 patients (7.8%) the symptomswere interfering with normal function. The mostannoying symptom was permanent unilateralnasal obstruction followed by long lasting PND,anosmia and altered voice resonance. Fivepatients eventually underwent surgery due totheir functional problems. Examination ofpatients 6 month after surgery, the retainedseptal deviation was present in 24 patients fromwhich 11 ones were symptomatic. Obstructionof internal nasal valve was evident in 3 patientsand collapse of external valve was present in 2cases. All the cases with internal or externalvalve disorders were symptomatic. One patientdiagnosed with chronic rhinosinusitis, whichwas confirmed afterward by imaging techniques.In 5 symptomatic patients there was no obviousabnormality in physical examination. Fourpatients underwent revision surgery due tofunctional issues. In one case, functional andaesthetic issues treated simultaneously in arevision surgery.DISCUSSIONRhinoplasty is one of the most common aestheticsurgeries around the world. Nose and paranasalsinuses have very complicated anatomy andnumerous factors can alter the function of theairway and drainage of sinuses (1, 3). The valveareas of the nasal airflow passage have specialimportance during rhinoplasty. Duringrhinoplasty, the relation between nasal bones,upper lateral cartilage and nasal septum usuallyalters and the internal valve area is prone tochange. This area has triangular shape and isconfined by upper lateral cartilage laterally, nasalseptum medially and inferior turbinate inferiorly(4). Disruption of the normal relation betweenupper lateral cartilages without an appropriatereconstruction, will lead to internal valvestrictures, which can cause nasal obstruction evenin the presence of a straight septum. Externalvalve, on the other hand, is confined by lowerlateral cartilage laterally, vestibular part of thenasal septum medially and nasal seal inferiorly.This area may be involved when the lateral cruraof the lower lateral cartilage is weakened due toover resection or when it is weak by its own andis not addressed during the surgery (5, 6). A weakala may pinch during inspiration and cause nasalobstruction. Theoretically, narrowing of the bonypyramid of the nose following aggressive lateralosteotomy can interfere with normal airflow.Figure 1. Primary symptoms14%19%38%AnosmiaPNDNasalObstruction5%5%9%10%Anterior palatalanesthesiaAbnormal nasaltip sensationHyponasalspeechHeadache11 Post-rhinoplasty Sinonasal Symptoms©2015 Publisher: Hearing Disorders Research Center, Shahid Beheshti University of Medical Sciences. All rights Reserved.Adhesion and scars are other causes of nasalobstruction following any surgery that involvesarea including rhinoplasty and septorhinoplasty(7, 8 and 9).Any change in the nasal airflow or drainage ofthe sinuses may lead to chronic mucosal changeand abnormal secretions from mucosal gland.This secretion usually presents as postnasaldischarges (PND). This is a very common butnon-specific symptom which happens in almostall sinonasal abnormalities. Some PND aftersurgical manipulation of the nose and paranasalsinuses may be considered normal but longlasting PND (lasthng more than 6 weeks) needscareful consideration (10).Anosmia may be secondary to nasal blockageafter surgery. A normal airflow contacting theolfactory mucosa is required for olfaction and inthe lack of normal airflow there would be nosense of smell. On the other hand, surgicaltrauma specialty in anterior skull base may leadto partial or even complete injury of the fibers ofthe olfactory nerve that result inpermanentolfactory loss (11, 12).Hyponasal speech usually arises from anobstruction that blocks the airflow from nasalpassages either in nasopharynx or nasal cavities.In post-operative patients, altering of thecharacteristics of the nasal passages usuallyleads to a change in the resonance of the nose,which is almost always, hyponasality. It maybecome the first and the most annoyingsymptom of the patient (3).Headache after surgical manipulation of the noseand nasal cavity may have numerous reasons.An underlying headache may exist and it may beflared up after surgery and anesthesia. On theother hand, headache may be a presentation ofthe underlying sinonasal inflammatory disease.An important issue will be rhinogenic contactpoint headache (RCPH), which is a headachethat arises from contact between two opposingmucosal surfaces. There may be someabnormalities in the nasal cavity and afterperforming osteotomies and cartilaginousmanipulations, this underlying anatomicalvariations show themselves as mucosal contactsand RCPH. This kind of headache is relativelyhard to be diagnosed and rolling out otherpossibilities in the presence of a supportingimaging study often would make the appropriatediagnosis (5).In our study, the most common symptom wasnasal obstruction. According to Palesy T. et al.,successful rhinoplasty has little effect onresistance in nasal valve. Patient may feel arelief because of appropriate changes incollapsibility of the area. The authorsemphasized on the importance of lateral nasalwall reconstruction after surgery, which maylead to valve problem and consequently nasalobstruction (1).Adamson PA et al. also statedthat successful reconstruction of a vestibularstenosis, airflow indexes come back to normalratios and nasal obstruction relives (2).We can justify our results about nasalobstruction by discussing about the problemsthat can lead to this symptom. Obviously nasalseptal deviation and valve area conditionsshould move toward more favorable conditionsduring septorhinoplasty. A complicated anatomythat is usually seen in crocked or cleft noses mayrestrict the surgeon’s hand to achieve its goals,which will leave the nose with a partiallyobstructed valve or cavity. On the other hand,adhesions and narrowing of air passagesecondary to osteotomies may contribute to thepost-operative results.There are not many reports with direct focus onpostoperative symptom in rhinoplasty. PND hasnot been mentioned in literature as a possiblesymptom following sinonasal manipulation.Nonetheless, when PND occurs, it is very hardto treat. This might be due to its multifactorialetiology that one cannot understand where toaddress for appropriate management of thisdisorder. When PND happens after surgery, itmay be due to a new sinonasal disease. Webelieve every one with long-lasting PND,especially when it starts after surgery and doesnot relive in a reasonable time, needs to beevaluated by imaging modalities. Upondiagnosis of rhinosinusitis, an appropriatemedical or surgical treatment should be initiated.Although Razmpa et al., noted that rhinoplastydid not alter the olfactory function (11).Ourresults showed that, up to 2.6% of patientsexperienced olfactory malfunction following thesurgery. This risk must be mentioned in pre-operative interview sessions. We found noreport about the relation between hyponasalityand rhinoplasty. There are a considerablepercentage of patients who experiencedresonance problem especially hyponasality aftersurgery. In some of these patients nasalobstruction is not evident or it is minimal. Webelieve that resonance problems should beconsidered as a separate complication of thesurgery. It is very hard to treat and should bementioned in pre-operative interview sessions.Ahmady Roozbahany N. et al.12©2015 Publisher: Hearing Disorders Research Center, Shahid Beheshti University of Medical Sciences. All rights Reserved.In our patients, no new headache case neededrevision surgery. It seems reasonable to look forthe possible etiologies of a new headachefollowing the surgery and try to treat it withsurgical revision.CONCLUSIONRhinoplasty and septorhinoplasty have numerouscomplications. the most common complicationsare Nasal obstruction, PND and anosmia. Acareful follow-up is required for diagnosis andappropriate treatment of these complications.ACKNOWLEDGEMENTSWe would like to thank all patients whoparticipated in this study. We also would like toappreciate the support of clinical researchdevelopment center of Loghman Hakim hospital.REFERENCES1. Palesy T, Pratt E, Mrad N, Marcells GN, Harvey RJ.Airflow and patient-perceived improvement followingrhinoplastic correction of external nasal valvedysfunction. JAMA facial plastic surgery.2015;17(2):131-6.2. Adamson PA, McGraw-Wall BL, Strecker HD,Gillman GS. Analysis of nasal air flow followingrepair of vestibular stenosis. The Journal ofotolaryngology. 1998;27(4):200-5.3. Constantian MB. Differing characteristics in 100consecutive secondary rhinoplasty patients followingclosed versus open surgical approaches. Plastic andreconstructive surgery. 2002;109(6):2097-111.4. Lindsay RW. Disease-specific quality of lifeoutcomes in functional rhinoplasty. TheLaryngoscope. 2012;122(7):1480-8.5. Edizer DT, Erisir F, Alimoglu Y, Gokce S. Nasalobstruction following septorhinoplasty: how welldoes acoustic rhinometry work? European archives ofoto-rhino-laryngology : official journal of theEuropean Federation of Oto-Rhino-LaryngologicalSocieties (EUFOS) : affiliated with the GermanSociety for Oto-Rhino-Laryngology - Head and NeckSurgery. 2013;270(2):609-13.6. Thomson C, Mendelsohn M. Reducing theincidence of revision rhinoplasty. The Journal ofotolaryngology. 2007;36(2):130-4.7. Ophir D. Resection of obstructing inferiorturbinates following rhinoplasty. Plastic andreconstructive surgery. 1990;85(5):724-7.8. Sheen JH. Rhinoplasty: personal evolution andmilestones. Plastic and reconstructive surgery.2000;105(5):1820-52; discussion 53.9. Constantian MB. The incompetent external nasalvalve: pathophysiology and treatment in primary andsecondary rhinoplasty. Plastic and reconstructivesurgery. 1994;93(5):919-31; discussion 32-3.10. Hahn S, Becker DG. What are some tips andpearls for preserving and improving nasal functionwhen performing a cosmetic rhinoplasty? Currentopinion in otolaryngology & head and neck surgery.2014;22(1):58-62.11. Razmpa E, Saedi B, Safavi A, Mohammadi S.Olfactory function after nasal plastic surgery. B-ent.2013;9(4):269-75

Post-rhinoplasty Sinonasal Symptoms

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Post-rhinoplasty Sinonasal Symptoms

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