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Functional tension nose as a cause of nasal airway obstruction
Auris Nasus Larynx 34 (2007) 313–317 www.elsevier.com/locate/anl
Functional tension nose as a cause of nasal airway obstruction Ilias V. Kantas a,*, Chariton E. Papadakis b, Dimitrios G. Balatsouras c, Marinos Vafiadis d, Stavros G. Korres e, Aggeliki Panagiotakopoulou a, Vassilios Danielidis d a
ENT Department of ‘‘G. Genimmatas’’ General Hospital, Thessaloniki, Greece b ENT Department of Chania General Hospital, Chania, Crete, Greece c ENT Department of Tzanion General Hospital, Piraeus, Greece d ENT Department of Demokrition University of Thrace, Alexandroupolis, Greece e ENT Department of University of Athens, Athens, Greece Received 18 May 2006; accepted 19 January 2007 Available online 26 March 2007
Abstract Objective: The purpose of this prospective study was to evaluate the influence of functional tension nose in nasal obstruction and to discuss its frequency and management. Methods: Over the years 2000–2006, 153 patients underwent revision operation for nasal obstruction in our rhinoplastic center. Twenty-two of them (14.37%) suffered from functional tension nose. All 22 patients refused rhinoplasty during primary septoplasty. Sixteen of them had a kyphotic nose and the rest six cases suffered from hanging columella (drooped nose). Eighteen of them underwent primary rhinoplasty in combination with caudal diminution under general anesthesia. The other four patients refused rhinoplasty, and under local anesthesia their tip was deprojected and reprojected. Results: Marked improvement in nasal airflow was noted at the most recent follow-up evaluation in 20 patients out of 22 (90.91%). The mean length of follow-up was 8 months (ranging from 4 to 12 months). All follow-up results were based on office examination and pre- and postoperative computer-assisted rhinomanometry evaluation. In only two cases results were not efficient enough. Conclusion: Our study strongly suggests that tension nose is a usual misdiagnosed cause of nasal obstruction. This problem is concealed under a ‘‘kyphotic’’, ‘‘big’’, or ‘‘pinocchio’’ nose. Usually the functional defect is spontaneously corrected during conventional rhinoplasty. However, tip should be deprojected and reprojected in cases where the patient refuses cosmetic intervention and surgeon tries to resolve his functional problem. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Tension nose; Nasal obstruction; Rhinoplasty; Kyphotic nose; Drooped nose
1. Introduction Nasal airway obstruction is a common subjective complaint defined as a feeling of insufficient airflow through the nose. Usually is a multifactorial problem. The main factors contributing to this problem are septal deviation in combination with turbinate hypertrophy as the main common factor. Nasal valve collapse or narrowing is also a common cause of nasal airway obstruction in cases where * Corresponding author at: 5 M. Alexandrou Street, 43100 Karditsa, Greece. Tel.: +30 24410 71727; fax: +30 24410 71727. E-mail address: [email protected] (I.V. Kantas).
nasal valve mechanical integrity fails to resist the negative pressure during aspiration. A variety of approaches have been devised to treat the above problems [1–9]. We present another factor which leads to nasal obstruction, and in most cases is misdiagnosed. Tension nose is a term which has been coined by Cottle [10] with a high nasal dorsum usually combined with long caudal edge with stretching of the skin and soft tissue resulting in narrowing the nasal valve. The angle between the tip and supratip regions is important for the aesthetic appearance of the nose and inspiration efficacy as well. In patients suffering from functional tension nose the anterior septal angle (Fig. 1) is located above the tip defining point (the
0385-8146/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2007.01.012
314
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
bibliography of a similar study led us to consider the frequency and management of this problem.
2. Materials and methods
Fig. 1. Relationship between the levels of tip defining point (b) and anterior septal angle (a1) pre- and (a2) post-operatively. Correction of cosmetic and functional problem (septorhinoplasty).
most prominent area of the dome of the lobular cartilage) (Fig. 2) [11]. This anatomic variation leads to aesthetic nose disharmony and severe nasal obstruction owing to narrow valve resulting in pulling down the upper lateral cartilage [12]. Candidate patients for revision operation after failed primary septoplasty were considered a valid material for studying the frequency of functional tension nose resulting in nasal airway obstruction. The lack in the international
Fig. 2. Tip defining point (arrow).
Over the years 2000–2006, 153 patients underwent revision operation for nasal obstruction in our rhinoplastic center. Twenty-two of them (14.37%), 13 females and 9 males, suffered from functional tension nose. Sixteen out of the twenty-two patients had a kyphotic nose and in the remaining six patients both parts of caudal and dorsal septum were protruding leading to hanging columella (drooping nose). All the 22 patients refused rhinoplasty during primary septoplasty. The Cottle maneuver was considered negative during clinical examination when airflow was not subjectively improved with upper and lateral traction on the nasofacial groove. However, airway patency was subjectively impressively improved during rising of the nasal tip. According to our experience, this maneuver in combination with the Cottle maneuver is helpful in establishing the diagnosis of functional tension nose. All patients (13 females and 9 males) underwent active anterior rhinomanometry (AAR) and acoustic rhinometry (AR), in order to evaluate the intranasal findings objectively. After suctioning the nasal cavities, decongestant (xylometazoline hydrochloride) was locally applied and AAR and AR were performed 10– 20 min after decongestion. The A1 acoustic rhinometer and the NR6 rhinomanometer (GM Instruments Ltd., Kilwinning, UK) and adequate software (NR6RHINO Version
Fig. 3. Correction of functional problem, after diminution of the redundant septal segments (a) dorsal, (b) caudal septum and (c) nasal spur (arrowhead), respectively. (Tip reprojection) Pre- and post-operative septal levels (compact and interrupted lines, respectively) in correlation to the tip defining point (black arrow).
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
3.11) were used. The equipment detected minimal crosssection area (MCA), inspiratory nasal flow and nasal resistance at the 150 Pa reference pressure. In AAR, both nasal cavities were measured separately and nasal resistance was accepted after 10 respirations if maximal variation coefficient was 5%. In AR, acoustic rhinograms for each nasal cavity were accepted after averaging three rhinograms within the limits of maximum 2% standard deviation (S.D.). All patients were retested 3 months postoperatively, for evaluation of the surgical outcome, under the same conditions and using identical equipment. Data regarding minimal cross-section areas, nasal flow and nasal resistances were expressed as mean S.D. Eighteen patients underwent primary rhinoplasty. Under general anesthesia a closed technique was chosen. Correction of the profile by hump reduction, lateral osteotomies and septal caudal diminution was performed (Fig. 1). The achieved cranial tip rotation resulted in modification of the angle between the nasal wings and the columella, resolving, thus, aesthetical and nasal obstruction problems. The other four patients refused rhinoplasty. In these patients, operation was performed under local anesthesia by shortening the anterior septum either basally or dorsally, and moving anterior septal angle inferior to the level of the tip defining point (Fig. 2). Care was taken when caudal septal edge was shaped to prevent nostrils from looking as ‘‘gun
315
barrels’’. This small change, often less than 1–2 mm, could dramatically change the angle between the tip defining point and the anterior septal angle (Figs. 1 and 3), resulting in nasal valve relaxation and widening and thus impressively improving nasal obstruction. The patients were followed up at 2 weeks and 1 month postoperatively and afterwards every 3 months for a period ranging from 4 to 12 months.
3. Results The mean length of follow-up was 8 months (ranging from 4 to 12 months). All follow-up results were based on office evaluation.
3.1. Functional results Postoperative rhinomanometric measurements (Table 1) demonstrated a statistically significant nasal flow increase at 3 months postoperatively. Nasal resistance was found also reduced, although not in a statistically significant level. The acoustic rhinometric data showed a significant MCA increase. These data proved a significant improvement of nasal airway in all patients.
Fig. 4. A 25-year-old patient suffered functional (kyphotic) tension nose. Preoperative and postoperative status (profile + base views).
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I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
Table 1 Acoustic rhinometry and active anterior rhinomanometry measurements in 22 patients (results for right and left nasal cavities were combined)
Follow-up clinical evaluation also proved marked improvement in nasal airflow in 20 patients out of 22 (90.91%) patients. Two patients, out of the four patients who refused rhinoplasty (9.09%), felt moderate improvement of nasal obstruction. The first occurred in a young man who had undergone 2 prior septoplasty–turbinectomy procedures resulting in septal perforation and turbinate over-resection, respectively, and who had sustained postoperative crusting to the nose after each procedure. The second patient had undergone prior septoplasty with turbinectomy, during which turbinates were over-resected. He was a 54-yearold man with a ‘‘kyphotic’’ nose who complained about asymmetrical improvement of nasal airway obstruction after nasal tip reprojection. This complaint was assumed to be a subjective feeling due to turbinate over-resection.
3.2. Cosmetic results In addition to functional airway improvement, there was substantial cosmetic improvement in nasal appearance in 18 patients who underwent rhinoplasty. The cosmetic results were based on photographic documentation and subjective patient satisfaction. The hanging columella was corrected, the disfigured nasal tip was restored and new natural contour and nasal profile was established (Figs. 4 and 5). In the four cases that refused aesthetic intervention, the cosmetic results were not sufficient enough after nasal tip reprojection (rotation) alone.
4. Discussion Tension nose is usually combined with nasal cosmetic deformities caused by hypertrophy of the cartilaginous or bone framework of the nose or both. In tension nose the anterior septal angle is upper than the tip defining point. This results in pulling down the upper lateral cartilage and inner nasal valve narrowing. Terms like ‘‘kyphotic’’, ‘‘big’’ or ‘‘pinocchio’’ nose describe the above deformities. This abnormal septal growth affects not only the dorsum and vault of the nose, but also its tip projection. Furthermore, it pushes the lower lateral cartilage forward, thus decreasing
Fig. 5. A 22-year-old patient suffered tension nose (long nose-pinocchio deformity). Preoperatively and postoperatively, after correction (profile + base views).
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
the inner valve, and resulting in breathing difficulty. This combination of cosmetic disharmony and deficiency of nasal airway patency has been recognized by many authors, who have reported a number of different techniques to improve both of nasal appearance and ventilation sufficiency [13,14]. Johnson and Codin [15] divided tension nose in a fourstage rating system. He classified 0 stage in cases of no tension deformity and 1, 2 or 3 stage according to the degree of the anterior displacement of the nasal base and the effect on the upper lip projection – light, moderate and severe – respectively. According to our experience, the diagnostic clinical sign for this case is the subjectively impressive improvement of nasal airway patency during nasal tip rising. In contrast, Cottle maneuver is negative in all of these cases. The key to the correction of functional problem in tension nose is surgeon to recognize the problem. The need for deprojection in these noses is more than obvious. However, many times patients have compromised with their cosmetic problems, asking for resolving only their functional problem of nasal airway obstruction. If the anatomic basis for this problem is not recognized at the time of clinical examination – preoperatively as it has been described above – the function result is likely to suffer. Correction of the complex septum-turbinate in these cases is inadequate to improve nasal obstruction. Many surgeons, lacking knowledge of the importance of this specific part of nasal structure (nasal tip projection), overlook its functional value. Many of patients have been led to psychotherapist for psychological supporting after having undergone prior failed septoplasty and inferior turbinectomy procedures. Although the problem of tension nose is not mentioned routinely in the literature, we believe that it occurs frequently enough in combination with ‘‘kyphotic’’, ‘‘pinocchio’’ or ‘‘big’’ nose. The resolution of this problem is quite simple. Most of the above patients underwent septorhinoplasty during which their problem is spontaneously resolved. However, many patients refuse to correct their cosmetic appearance and present only for correcting their functional problem. Trimming a small piece of 1–2 mm at the caudal septum is adequate to move anterior septal angle inferior to the tip defining point, thus resolving nasal ventilation. Our study suggests that functional tension nose is responsible for the significant percentage (14.37%) of revised cases for nasal airway insufficiency and that the postoperative functional good results (90.91%) were based on the right diagnosis and management of the problem. Surgeon should kept on his mind the specific anatomic relationships between defining point and anterior septal angle, which seems to be suffering in models of nose mentioned above. Specific care should be paid for all these
317
models of nose, where patient is interested only of nasal ventilation improvement. Modifying the angle between the tip and supratip region can bring about a clear improvement in the profile and a comfortable nasal breathing.
5. Conclusion Tip over-projection is not only responsible for nasal cosmetic appearance, but for nasal breathing difficulties also. This problem is concealed under a ‘‘kyphotic’’, ‘‘big’’, or ‘‘pinocchio’’ nose. Usually the functional defect is spontaneously corrected during conventional rhinoplasty. However, tip should be deprojected and reprojected by tip rotation in cases where patient refuses cosmetic intervention and surgeon attempts to correct his functional problem.
References [1] Cottle MH. An introduction to conservative septum—pyramid surgery. Intern Rhinol 1964;2:11–24. [2] Goldman IB. New technique in surgery of the deviated nasal septum. Arch Otolaryngol Head Neck Surg 1956;64:183. [3] Rees T. Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft. Plast Reconstr Surg 1986;78:320. [4] Mucci S, Sismanis A. Inferior partial turbinectomy: an effective procedure for chronic rhinitis. Ear Nose Throat J 1994;73:405–7. [5] Ophir D, Shapira A, Marshak G. Total inferior turbinectomy for nasal airway obstruction. Arch Otolaryngol Head Neck Surg 1985;111:93– 5. [6] Davis WE, Nishioka GJ. Endoscopic partial inferior turbinectomy using a power microcutting instrument. Ear Nose Throat J 1996;75:49–50. [7] Ozturan O, Miman MC, Kizilay A. Bending of the upper lateral cartilages for nasal valve collapse. Arch Facial Plast Surg 2002;4:258– 61. [8] Paniello RC. Nasal valve suspension. An effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg 1996;122:1342–6. [9] Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Rec Surg 1998;101:1120–2. [10] Cottle MH. The Cottle nasal syndromes. In: Rhinology: the collected writing of Maurice H. Cottle. The American Rhinologic Society; 1987. p. 189–90. [11] Huizing EH, de Groot JAM. Basics. In: Huizing EH, de Groot JAM, editors. Functional reconstructive nasal surgery. Stuttgart: Thieme; 2003. p. 1–56. [12] Rees T. Aesthetic plastic surgery I. Philadelphia: Saunders; 1980. p. 77–92. [13] Gola R. Functional and esthetic rhinoplasty. Aesth Plast Surg 2003;27:390–6. [14] Gubisch W. Die große Nase-ein a¨sthetisches, aber auch ein funktionelles Problem. Laryngo-Rhino-Otol 1994;244–8. [15] Johnson CM, Codin MS. The tension nose: open structure rhinoplasty approach. Plast Reconstr Surg 1995;95:43–51.
Functional tension nose as a cause of nasal airway obstruction Ilias V. Kantas a,*, Chariton E. Papadakis b, Dimitrios G. Balatsouras c, Marinos Vafiadis d, Stavros G. Korres e, Aggeliki Panagiotakopoulou a, Vassilios Danielidis d a
ENT Department of ‘‘G. Genimmatas’’ General Hospital, Thessaloniki, Greece b ENT Department of Chania General Hospital, Chania, Crete, Greece c ENT Department of Tzanion General Hospital, Piraeus, Greece d ENT Department of Demokrition University of Thrace, Alexandroupolis, Greece e ENT Department of University of Athens, Athens, Greece Received 18 May 2006; accepted 19 January 2007 Available online 26 March 2007
Abstract Objective: The purpose of this prospective study was to evaluate the influence of functional tension nose in nasal obstruction and to discuss its frequency and management. Methods: Over the years 2000–2006, 153 patients underwent revision operation for nasal obstruction in our rhinoplastic center. Twenty-two of them (14.37%) suffered from functional tension nose. All 22 patients refused rhinoplasty during primary septoplasty. Sixteen of them had a kyphotic nose and the rest six cases suffered from hanging columella (drooped nose). Eighteen of them underwent primary rhinoplasty in combination with caudal diminution under general anesthesia. The other four patients refused rhinoplasty, and under local anesthesia their tip was deprojected and reprojected. Results: Marked improvement in nasal airflow was noted at the most recent follow-up evaluation in 20 patients out of 22 (90.91%). The mean length of follow-up was 8 months (ranging from 4 to 12 months). All follow-up results were based on office examination and pre- and postoperative computer-assisted rhinomanometry evaluation. In only two cases results were not efficient enough. Conclusion: Our study strongly suggests that tension nose is a usual misdiagnosed cause of nasal obstruction. This problem is concealed under a ‘‘kyphotic’’, ‘‘big’’, or ‘‘pinocchio’’ nose. Usually the functional defect is spontaneously corrected during conventional rhinoplasty. However, tip should be deprojected and reprojected in cases where the patient refuses cosmetic intervention and surgeon tries to resolve his functional problem. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Tension nose; Nasal obstruction; Rhinoplasty; Kyphotic nose; Drooped nose
1. Introduction Nasal airway obstruction is a common subjective complaint defined as a feeling of insufficient airflow through the nose. Usually is a multifactorial problem. The main factors contributing to this problem are septal deviation in combination with turbinate hypertrophy as the main common factor. Nasal valve collapse or narrowing is also a common cause of nasal airway obstruction in cases where * Corresponding author at: 5 M. Alexandrou Street, 43100 Karditsa, Greece. Tel.: +30 24410 71727; fax: +30 24410 71727. E-mail address: [email protected] (I.V. Kantas).
nasal valve mechanical integrity fails to resist the negative pressure during aspiration. A variety of approaches have been devised to treat the above problems [1–9]. We present another factor which leads to nasal obstruction, and in most cases is misdiagnosed. Tension nose is a term which has been coined by Cottle [10] with a high nasal dorsum usually combined with long caudal edge with stretching of the skin and soft tissue resulting in narrowing the nasal valve. The angle between the tip and supratip regions is important for the aesthetic appearance of the nose and inspiration efficacy as well. In patients suffering from functional tension nose the anterior septal angle (Fig. 1) is located above the tip defining point (the
0385-8146/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2007.01.012
314
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
bibliography of a similar study led us to consider the frequency and management of this problem.
2. Materials and methods
Fig. 1. Relationship between the levels of tip defining point (b) and anterior septal angle (a1) pre- and (a2) post-operatively. Correction of cosmetic and functional problem (septorhinoplasty).
most prominent area of the dome of the lobular cartilage) (Fig. 2) [11]. This anatomic variation leads to aesthetic nose disharmony and severe nasal obstruction owing to narrow valve resulting in pulling down the upper lateral cartilage [12]. Candidate patients for revision operation after failed primary septoplasty were considered a valid material for studying the frequency of functional tension nose resulting in nasal airway obstruction. The lack in the international
Fig. 2. Tip defining point (arrow).
Over the years 2000–2006, 153 patients underwent revision operation for nasal obstruction in our rhinoplastic center. Twenty-two of them (14.37%), 13 females and 9 males, suffered from functional tension nose. Sixteen out of the twenty-two patients had a kyphotic nose and in the remaining six patients both parts of caudal and dorsal septum were protruding leading to hanging columella (drooping nose). All the 22 patients refused rhinoplasty during primary septoplasty. The Cottle maneuver was considered negative during clinical examination when airflow was not subjectively improved with upper and lateral traction on the nasofacial groove. However, airway patency was subjectively impressively improved during rising of the nasal tip. According to our experience, this maneuver in combination with the Cottle maneuver is helpful in establishing the diagnosis of functional tension nose. All patients (13 females and 9 males) underwent active anterior rhinomanometry (AAR) and acoustic rhinometry (AR), in order to evaluate the intranasal findings objectively. After suctioning the nasal cavities, decongestant (xylometazoline hydrochloride) was locally applied and AAR and AR were performed 10– 20 min after decongestion. The A1 acoustic rhinometer and the NR6 rhinomanometer (GM Instruments Ltd., Kilwinning, UK) and adequate software (NR6RHINO Version
Fig. 3. Correction of functional problem, after diminution of the redundant septal segments (a) dorsal, (b) caudal septum and (c) nasal spur (arrowhead), respectively. (Tip reprojection) Pre- and post-operative septal levels (compact and interrupted lines, respectively) in correlation to the tip defining point (black arrow).
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
3.11) were used. The equipment detected minimal crosssection area (MCA), inspiratory nasal flow and nasal resistance at the 150 Pa reference pressure. In AAR, both nasal cavities were measured separately and nasal resistance was accepted after 10 respirations if maximal variation coefficient was 5%. In AR, acoustic rhinograms for each nasal cavity were accepted after averaging three rhinograms within the limits of maximum 2% standard deviation (S.D.). All patients were retested 3 months postoperatively, for evaluation of the surgical outcome, under the same conditions and using identical equipment. Data regarding minimal cross-section areas, nasal flow and nasal resistances were expressed as mean S.D. Eighteen patients underwent primary rhinoplasty. Under general anesthesia a closed technique was chosen. Correction of the profile by hump reduction, lateral osteotomies and septal caudal diminution was performed (Fig. 1). The achieved cranial tip rotation resulted in modification of the angle between the nasal wings and the columella, resolving, thus, aesthetical and nasal obstruction problems. The other four patients refused rhinoplasty. In these patients, operation was performed under local anesthesia by shortening the anterior septum either basally or dorsally, and moving anterior septal angle inferior to the level of the tip defining point (Fig. 2). Care was taken when caudal septal edge was shaped to prevent nostrils from looking as ‘‘gun
315
barrels’’. This small change, often less than 1–2 mm, could dramatically change the angle between the tip defining point and the anterior septal angle (Figs. 1 and 3), resulting in nasal valve relaxation and widening and thus impressively improving nasal obstruction. The patients were followed up at 2 weeks and 1 month postoperatively and afterwards every 3 months for a period ranging from 4 to 12 months.
3. Results The mean length of follow-up was 8 months (ranging from 4 to 12 months). All follow-up results were based on office evaluation.
3.1. Functional results Postoperative rhinomanometric measurements (Table 1) demonstrated a statistically significant nasal flow increase at 3 months postoperatively. Nasal resistance was found also reduced, although not in a statistically significant level. The acoustic rhinometric data showed a significant MCA increase. These data proved a significant improvement of nasal airway in all patients.
Fig. 4. A 25-year-old patient suffered functional (kyphotic) tension nose. Preoperative and postoperative status (profile + base views).
316
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
Table 1 Acoustic rhinometry and active anterior rhinomanometry measurements in 22 patients (results for right and left nasal cavities were combined)
Follow-up clinical evaluation also proved marked improvement in nasal airflow in 20 patients out of 22 (90.91%) patients. Two patients, out of the four patients who refused rhinoplasty (9.09%), felt moderate improvement of nasal obstruction. The first occurred in a young man who had undergone 2 prior septoplasty–turbinectomy procedures resulting in septal perforation and turbinate over-resection, respectively, and who had sustained postoperative crusting to the nose after each procedure. The second patient had undergone prior septoplasty with turbinectomy, during which turbinates were over-resected. He was a 54-yearold man with a ‘‘kyphotic’’ nose who complained about asymmetrical improvement of nasal airway obstruction after nasal tip reprojection. This complaint was assumed to be a subjective feeling due to turbinate over-resection.
3.2. Cosmetic results In addition to functional airway improvement, there was substantial cosmetic improvement in nasal appearance in 18 patients who underwent rhinoplasty. The cosmetic results were based on photographic documentation and subjective patient satisfaction. The hanging columella was corrected, the disfigured nasal tip was restored and new natural contour and nasal profile was established (Figs. 4 and 5). In the four cases that refused aesthetic intervention, the cosmetic results were not sufficient enough after nasal tip reprojection (rotation) alone.
4. Discussion Tension nose is usually combined with nasal cosmetic deformities caused by hypertrophy of the cartilaginous or bone framework of the nose or both. In tension nose the anterior septal angle is upper than the tip defining point. This results in pulling down the upper lateral cartilage and inner nasal valve narrowing. Terms like ‘‘kyphotic’’, ‘‘big’’ or ‘‘pinocchio’’ nose describe the above deformities. This abnormal septal growth affects not only the dorsum and vault of the nose, but also its tip projection. Furthermore, it pushes the lower lateral cartilage forward, thus decreasing
Fig. 5. A 22-year-old patient suffered tension nose (long nose-pinocchio deformity). Preoperatively and postoperatively, after correction (profile + base views).
I.V. Kantas et al. / Auris Nasus Larynx 34 (2007) 313–317
the inner valve, and resulting in breathing difficulty. This combination of cosmetic disharmony and deficiency of nasal airway patency has been recognized by many authors, who have reported a number of different techniques to improve both of nasal appearance and ventilation sufficiency [13,14]. Johnson and Codin [15] divided tension nose in a fourstage rating system. He classified 0 stage in cases of no tension deformity and 1, 2 or 3 stage according to the degree of the anterior displacement of the nasal base and the effect on the upper lip projection – light, moderate and severe – respectively. According to our experience, the diagnostic clinical sign for this case is the subjectively impressive improvement of nasal airway patency during nasal tip rising. In contrast, Cottle maneuver is negative in all of these cases. The key to the correction of functional problem in tension nose is surgeon to recognize the problem. The need for deprojection in these noses is more than obvious. However, many times patients have compromised with their cosmetic problems, asking for resolving only their functional problem of nasal airway obstruction. If the anatomic basis for this problem is not recognized at the time of clinical examination – preoperatively as it has been described above – the function result is likely to suffer. Correction of the complex septum-turbinate in these cases is inadequate to improve nasal obstruction. Many surgeons, lacking knowledge of the importance of this specific part of nasal structure (nasal tip projection), overlook its functional value. Many of patients have been led to psychotherapist for psychological supporting after having undergone prior failed septoplasty and inferior turbinectomy procedures. Although the problem of tension nose is not mentioned routinely in the literature, we believe that it occurs frequently enough in combination with ‘‘kyphotic’’, ‘‘pinocchio’’ or ‘‘big’’ nose. The resolution of this problem is quite simple. Most of the above patients underwent septorhinoplasty during which their problem is spontaneously resolved. However, many patients refuse to correct their cosmetic appearance and present only for correcting their functional problem. Trimming a small piece of 1–2 mm at the caudal septum is adequate to move anterior septal angle inferior to the tip defining point, thus resolving nasal ventilation. Our study suggests that functional tension nose is responsible for the significant percentage (14.37%) of revised cases for nasal airway insufficiency and that the postoperative functional good results (90.91%) were based on the right diagnosis and management of the problem. Surgeon should kept on his mind the specific anatomic relationships between defining point and anterior septal angle, which seems to be suffering in models of nose mentioned above. Specific care should be paid for all these
317
models of nose, where patient is interested only of nasal ventilation improvement. Modifying the angle between the tip and supratip region can bring about a clear improvement in the profile and a comfortable nasal breathing.
5. Conclusion Tip over-projection is not only responsible for nasal cosmetic appearance, but for nasal breathing difficulties also. This problem is concealed under a ‘‘kyphotic’’, ‘‘big’’, or ‘‘pinocchio’’ nose. Usually the functional defect is spontaneously corrected during conventional rhinoplasty. However, tip should be deprojected and reprojected by tip rotation in cases where patient refuses cosmetic intervention and surgeon attempts to correct his functional problem.
References [1] Cottle MH. An introduction to conservative septum—pyramid surgery. Intern Rhinol 1964;2:11–24. [2] Goldman IB. New technique in surgery of the deviated nasal septum. Arch Otolaryngol Head Neck Surg 1956;64:183. [3] Rees T. Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft. Plast Reconstr Surg 1986;78:320. [4] Mucci S, Sismanis A. Inferior partial turbinectomy: an effective procedure for chronic rhinitis. Ear Nose Throat J 1994;73:405–7. [5] Ophir D, Shapira A, Marshak G. Total inferior turbinectomy for nasal airway obstruction. Arch Otolaryngol Head Neck Surg 1985;111:93– 5. [6] Davis WE, Nishioka GJ. Endoscopic partial inferior turbinectomy using a power microcutting instrument. Ear Nose Throat J 1996;75:49–50. [7] Ozturan O, Miman MC, Kizilay A. Bending of the upper lateral cartilages for nasal valve collapse. Arch Facial Plast Surg 2002;4:258– 61. [8] Paniello RC. Nasal valve suspension. An effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg 1996;122:1342–6. [9] Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Rec Surg 1998;101:1120–2. [10] Cottle MH. The Cottle nasal syndromes. In: Rhinology: the collected writing of Maurice H. Cottle. The American Rhinologic Society; 1987. p. 189–90. [11] Huizing EH, de Groot JAM. Basics. In: Huizing EH, de Groot JAM, editors. Functional reconstructive nasal surgery. Stuttgart: Thieme; 2003. p. 1–56. [12] Rees T. Aesthetic plastic surgery I. Philadelphia: Saunders; 1980. p. 77–92. [13] Gola R. Functional and esthetic rhinoplasty. Aesth Plast Surg 2003;27:390–6. [14] Gubisch W. Die große Nase-ein a¨sthetisches, aber auch ein funktionelles Problem. Laryngo-Rhino-Otol 1994;244–8. [15] Johnson CM, Codin MS. The tension nose: open structure rhinoplasty approach. Plast Reconstr Surg 1995;95:43–51.