Surgical Treatment of Nasal Obstruction


In the treatment of congestions that arise due to concha hypertrophy and generally cause more complaints at nights), reducing of concha as necessary may be achieved with different methods. Concha that has a very important role in the functions of the nose should never be excised completely.

OPERATIONS DIRECTED TO CONCHA

In the treatment of congestions that arise due to concha hypertrophy and generally cause more complaints at nights), reducing of concha as necessary may be achieved with different methods. Concha that has a very important role in the functions of the nose should never be excised completely. Following these types of surgeries, which have been frequently performed in the past, the functions of the nose deteriorates, in addition to its negative effects on the physiology of respiration, it is sometimes or impossible to resolve complaints like dryness, rind forming, recurrent infections and the feeling of burning that forms in the nose. Therefore, when lower concha is being educed today, techniques that do not damage the mucosa of the functional outer surface.

In most of the patients having a curved septum, the lower concha of the opposite nasal passage which is wider in volume (more in the lower concha) enlarges. Therefore, in most of the septum deviation surgeries, in order to achieve a satisfactory result in respect to respiration, during the same surgery, especially reducing of the concha in the nasal passage opposite the curvature are required to be reduced with an appropriate intervention. Otherwise, by getting the curved septum to the midline, the previously wide side will relatively narrow and if concha of this part that has adapted to the pre-surgery volume is not reduced, congestion will occur.

the most frequently used methods applied to reduce lower concha are radiofrequency and reducing the tissue volume under the mucosa without damaging it and in cases in which bony parts are also enlarged, reducing the soft tissue and bone tissue under the mucosa by cropping off (endoscopic reduction).

As a structural variation, air cell can be present inside the middle concha (concha bullosa). Enlargement of this air cell during growth inhibits the air flow in the middle nasal passage and at the same time may result in chronic sinusitis due to the obstruction in the sinus discharge channels located in the outer wall of the passage. Concha bullosa plasty should be applied to the middle concha that leads to these kinds of problems by using appropriate endoscopic surgery techniques. Though complete resection of middle concha does not result in a serious problem in the physiology of the nose, since these structures have a role as a guide for sinus interventions that may be performed in the future, they are not generally preferred to be removed completely.

Reducing of lower concha with radiofrequency
It is based on the principle of healing of the heat damage that is followed by the administration of radiofrequency energy to the soft tissues with rich vessel content found beneath the mucosa of lower concha by constriction and hardening. The hard scar tissue, forming within 2-3 months following the process results in shrinking in the concha and also prevents the widening that is formed with external stimuli or the position of the body.

In patients who do not require intervention to another pathology, lower concha radiofrequency can be applied under local anesthesia in the setting of an examination room (figure 1).

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Figure 1: Application of radiofrequency to lower concha. The concha shrinks following the application.

Concha radiofrequency operation that last approximately 5-10 minutes, can be performed easily during other operations such as nose surgeries for aesthetic or functional purposes, surgeries for chronic sinusitis and other surgeries that are performed in patients with the complaint of nasal congestion.

Since cutting is not performed during the operation, bleeding does not occur and therefore application of a compress is not required.

During and after this painless operation following a good local anesthesia, patients can return back to their daily activities immediately.

The ratio of yielding a successful result of the radiofrequency process that can be applied safely and comfortably in the treatment of lower concha enlargement that plays an important role in nasal congestions having serious negative effects on the quality of life within a single session is around 80%. Following the operation, the swelling that is formed in the lower concha or nasal congestion due to the tissue reaction on the surface of the mucosa may increase. The expected results of radiofrequency application emerge within 15-20 days. In nearly the 1/5 of the patients, since the opening of the nose is not completely obtained, the process may have to be applied again after a waiting period of 1.5-2 months.

In patients who yield successful result with radiofrequency, lower concha may enlarge again within 6 months-1 year if diseases like allergic rhinitis, vasomotor rhinitis are present, if the patients continuously stay in an environment with dry and dirty air, cigarette smoke or in a cold environment or if they use vasodilators. Repetition of the radiofrequency process or endoscopic concha reduction is recommended in these patients.

Though there is a disadvantage of recurrence of complaints, concha radiofrequency process is one of the most preferred procedures by the patients and the physicians since it has advantages like a high success rate, since it does not require compresses, and it may be applied under local anesthesia and does not result in bleeding.

Endoscopic concha reduction
It is the partial removal of soft tissues and the concha bone that are located under the lower concha.

This method usually is applied when the bone within the concha has an important role in concha enlargement, when desired results cannot be obtained with radiofrequency applications, when concha is extremely large or deformative or radiofrequency is not preferred due to the probability of recurrence.

The process in conducted under general anesthesia and when applied with microdebrider technology lasts for 5-10 minutes. Since the dimensions of the microdebrider device developed for concha are very small, the integrity of the mucosa is not destroyed during the process and therefore, endoscopic reduction surgeries may now be performed without the usage of compresses. Due to rich blood vessel content of concha, patients are recommended to rest for 72 hours against the probability of bleeding after the surgery.

Following the endoscopic concha reduction operation which is a highly effective method, concha is reduced to an important extent. With the help of new microdebriders, the posterior parts of the lower concha can be reached and concha with these widened or deformed parts can successfully be reduced. In some patients having this condition, partial resection or the application of radiofrequency to the posterior part of lower concha may be preferred.

Since Endoscopic reduction method is a technique that protects the mucosa of the concha, lower concha may enlarge again in the long term in patients diagnosed with diseases like allergic rhinitis, vasomotor rhinitis, if the patients continuously stay in an environment with dry and dirty air, cigarette smoke or in a cold environment or in patients using vasodilators. Application of radiofrequency with local anesthesia yields good results in these patients.


OPERATIONS FOR SEPTUM CURVATURE (DEVIATION)
When decision to perform surgery directed to deviation is taken, the complaints of the patient, the negative impact of the nasal congestion on health and quality of life should be considered along with the findings of the examination.

In patients diagnosed with obstructing apnea, though a significant congestion complaint is not present in the nose, the deviations and concha enlargements inside the nose may required to be eliminated and the air should have to be provided both to control apnea and also to use CPAP device.

In patient with nasal congestion complaint that is determined to be due to septum deviation, no alternative other than surgical treatment is present.

In deviation that are close to the back of the nose, with no excessive deformation in the cartilage that forms the anterior half of the septum and that do not include the bony skeleton of the nose, successful results may be obtained with standard operations that lasts for 20-30 minutes, applied through the nostrils.

In the presence of the defined problems, for patients who had undergone nose surgery and/or aesthetic interventions are planned in the same operation, "surgery with open technique should be preferred.

Today, with this method that has been preferred in aesthetic operations more frequently, it is possible to ideally and permanently correct the deviations of the cartilage and the bones without changing the outer appearance of the nose. In patients with cartilage deficiency or abnormality due to a previous operation, if sufficient amount of cartilage in the septum is not present, then pieces of cartilage taken from the ear lobe or the ribs may have to be used in the nose.

With the surgery techniques developed today, it is now possible to perform deviation and aesthetic nose surgeries without the use of compresses and this has an important contribution to the comfort of the patients after the surgery.

If the patients who have to undergo surgery due to deviation are thinking of undergoing an aesthetic surgery as well, the most ideal approach is performing the two operations at the same time. The usage of excess cartilage or bones that result in the deviation in the nose for the aesthetic operation is the most important advantage of the surgery that is performed simultaneously.

Deviation surgeries are preferably performed under general anesthesia and may last for 20-30 minutes with closed technique and for 1 to 2.5 hours with open technique according to the extent of the problem and the need for obtaining cartilage tissue from the ear or the rib.

In patients who do not undergo a process that requires the usage of compresses for lower concha at the same surgery, the operation directed for deviation is also performed without using compresses.

Patients usually stay at the hospital on the day of the surgery and discharged the next day by after cleaning the nose.

It is usually sufficient for patients to come back for controls for 2 or 3 times after the surgery. For dryness and rind formation that occurs for 2-3 weeks till the healing of the mucosa in the nose is completed, cleaning sprays containing saline and softening drops are used.

In patients who cannot undergo open technique surgery due to extreme cartilage deviation that affects the outer appearance or in patients who do not undergone an intervention for aesthetic purposes, the outer appearance of the nose does not change after the surgery, and swelling s or purple spots do not occur around the face and the eyes.

The patients have to protect their noses from impacts for a period of 6 weeks. They can start sports activities after 2 weeks, and start swimming after 1 month.

There is no objection to wear glasses for patients undergoing surgery for deviation.


OPERATIONS FOR NASAL VALVE INSUFFICIENCY
Nasal valve failure is observed in two different types as internal or external nasal valve failure.
Internal failures originate from the narrowing of nasal passage in the valve region due to the deviations that are found in the anterior part of cartilage septum, close to the back of the nose. In the treatment, with the open technique deviation surgery, this region is revealed and the deviation is corrected, and also the valve region may be widened to facilitate air flow with the help of cartilage grafts when necessary. The main problem in external failures is the collapsing of ear wings while inhaling and narrowing the air passage. This problem results from the reverse curvature of the cartilaginous structures inside the wings of the nose or occurs when it can not withstand the vacuum effect created by the air flow due to reasons like aesthetic surgeries, traumas or aging. In the treatment, techniques like supporting the weak regions with pieces of cartilage, correction of the cartilage angle that results in narrowing and preventing this collapsing with the help of sutures are used.



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