Functional rhinoplasty for ventilation disorder
Apart from the purely aesthetic rhinoplasty there are 2 further classification of nasal surgery: functional and reconstructive rhinoplasty. When performing a purely aesthetic surgery one aims for a more attractive nose shape considering the preservation of the normal respiration (ventilation). Functional rhinoplasty respectively septorhinoplasty is used to improve airway function, in other words a better ventilation of the nose. Reconstructive rhinoplasty, for example after trauma or tumors is performed to reconstruct shape and function of the nose.
The causes for a ventilation disorder can be various are most commonly the result of anatomical changes. It is necessary to differ between restriction of the airway through thickening of the nasal mucosae as with a cold or an allergie and the anatomical changes of cartilage and bones as with a deviated nasal septum, septal crest enlagerd nasal conchae.
Although a purely cosmetic rhinoplasty or a purely functional rhinoplasty represent separate procedures, there are patients that strive for a functional as well as cosmetical improvement.
Functional airway obstacles
Symptomes of a functional airway obstacle contain a blocked nose, mouth breathing (especially at night), a dry mouth or a reduced olfactory cognition. Secondary side effects of a chronically blocked nose can be noosebleed and reoccuring paranasal sinus infections. Through increasing pressure in the undrained paranasal sinuses headaches, disturbance of pressure equalizing between ear and nose (Eustachian tube) or sleep disorders may occur. If left untreated, these symptoms may promote the development of chronic ventilation disorders, including sleep disorders, high blood pressure, sleep apnea syndrome and even medical heart condition.
Diagnostics of ventilation disorders
A detailed questioning of the patient, followed by a thorough examination of the outer and inner nose (nostrils when in- and exhaling, nasal vestibule, valves, conchae and septum) are the basis of every procedure planning. For further diagnostics a rhinomanometry (airflow measurement), xray of the nose and the paranasal sinuses or a digital volume tomography (DVT) can give information about cartilaginous-bony changes. For these special examinations we will refer you to an ENT specialist or radiology.
Surgical treatment of the inner airways
In less complicated cases functional rhinoplasty involves the surgical treatment of the inner airways without changes to the outer nose. To help improving the ventilation, it may be also necessary to change the outer shape, for example to straighten a deviated nasal septum or to open up a tight inner nasal valve and to set in spreader grafts on the side of the nasal spetum on the level of the nasal bridge. These operations contain septorhinoplasty* (nasal septum straightening), conchae cautery (reduction of the cavernous body) and if necessary removal of nasal polyps. (*septorhinoplasty: straightening of a deviated nasal septum)
As a matter of principle these types of nasal deviations can be distinguished:
In the case of septorhinoplasty the septum deviding the right from the left nostril is deviated, lopsided, curved or twisted, which may lead to blockage of one or both airways ( generally known as deviated septum). Septoplasty uses a variaty of surgical techniques to straighten the nasal septum and to free the airways.
The cause of the deviation decides which technique is used:
Cartilaginous crooked nose:
It is essential to straighten the cartilaginous part of the nasal septum. If necessary the lateral nasal cartilages have to be released and therewith distortions removed. Spreader grafts (small cartilage splints to open the inner nasal valve) and positioning sutures are mostly part of the repositioning. A fixation of the laterally deviated nasal septums on the nasal spine ( protuberance on the base of the nostrils)
Bony crooked nose:
Here an asymmetry of the bony nasal pyramid is found. In this case the osteotomies, the sectioning of the bony walls has to be done asymmetrical if necessary. A removal of the hump to open the nasal roof may be needed to achieve a repositioning of the nasal axis.
C- or S-shaped deviation:
Here the decision has to be made if a bony-cartilaginous axis correction is performed, or if a straightening through augmentation (build-up) of the concave side with septal- or ear cartilage should take place.
The pseudo-crooked nose is not a malposition of the nasal axis but the appearance of a malpostion through different eye brow lines. It is essential to thoroughly annalyze facial asymmetry (eyebrow position, eye axis, cheek bones, upper and lower jaw deformities) and to discuss goals and operative possibilities with the patient in detail.
Conchae cautery- reduction of enlarged nasal conchae:
Enlarged nasal conchae, known as conchae hyperplasia, are another common reason for a ventilation disorder, especially in patients with long persisting allergies. Nasal conchae- that are mucosae-covered bony lamellas that enlage the surface of the nasal cavity. The are found at the outer wall of each nostril, where 3 conchae lie above each other (upper, middle, lower conchae), with the lower nasal conchae being the biggest. The upper conchae is generally very small and rarely the reason for a symptomatic airway disorder. However in some patients inner air pockets slowly develop within the middle conchae, which can lead to symptomatic airway obstacles- these malformation is known as concha bullosa. However, the enlargement of the lower concha, on the base of its size and its natural ability to answer environmental influence with growth, is one of the most common reasons for nasal airway blockage. Since conchae have the function to humidify, warm and filter the inhaled air, its rarely advisable to remove the complete conchal tissue. However, if the conchal tissue become to big and lead to functional airway disorders, a partial reduction of the conchae is indicated. This is a target-oriented surgical procedure, that can consideralbe improve nasal ventilation. Recovery is generally fast and painless, but the risc for a postoperative bleeding is increased for a few weeks until complete healing of the nasal mucosae.
Removal of nasal polyps:
Nasal polyps are benigne, grape shaped structures that sometimes obstruct the nasal airways. In less pronounced cases the removal is uncomplicated, but the likelihood of recurrent growth is high. Aggressive allergy treatment, especially for fungal allergies often reduced the risk of relapse.
Surgical treatment of the outer nasal skeleton:
While the removal of inner airway obstacles is often enough for some patients, greater nasal airway obstructions require surgical treatment of the outer nasal skeleton. Noses that are twisted, crooked, collapsed or too narrow (or a combination of all that) can’t be soleley enhanced with inner airway surgery. In this patient population rhinplasty techniques for straightening, widening and strengthening of the blocked outer nasal passage is necessary, to create free airway between nostrils and pharynx. These techniques are commonly known under the term “functional rhinoplasty”.
Health insurance contribution:
Although surgical changes of the nose, that only serves cosmetic enhancement, are not payed by the health insurance, functional disorders of the nasal airway are generally covered by most of the health insurance packages. Since it doen’t make sence to operate on the same body part twice, once to correct the functional disability and a second time to address the cosmetic issues, it’s best to combine the functional as well as the cosmetic goals in one operation. This not only prevents the additional risk and down time of a second operation, but it also increases the option of a successful result, as form and function of the nose are irrevocablye interconnected. Although medically necessary surgical procedures involve assumption of costs by the health insurance, the patient should take into consideration to hand in the cost estimate at his/her insurance asking to meet the costs prior to the planned operation. The costs vary significantly depending on the extent of the procedure.
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