Nasal surgery in patients with systemic disorders

Abstract

Multisystemic disorders represent a heterogenous group of diseases which can primarily manifest at the nose and paranasal sinuses as limited disease or secondarily as part of systemic involvement. Rhinologists therefore play an important role in the diagnostic but also therapeutic process. Although therapy of multisystemic disorders is primary systemic, additional rhinosurgery may become necessary. The spectrum of procedures consists of sinus surgery, surgery of the orbit and lacrimal duct, septorhinoplasty and closure of nasal septal perforation. Since the prevalence of most systemic diseases is very rare, recommendations are based on the analysis of single case reports and case series with a limited number of patients only. Although data is still limited, experiences published so far have shown that autologous cartilage or bone grafts can be used in nasal reconstruction of deformities caused by tuberculosis, leprosy, Wegener's granulomatosis, sarcoidosis and relapsing polychondritis. Experiences gained from these diseases support the concept that well-established techniques of septorhinoplasty can be used in systemic diseases as well. However, a state of remission is an essential condition before considering any rhinosurgery in these patients. Even under these circumstances revision surgery has to be expected more frequently compared to the typical collective of patients undergoing septorhinoplasty. In addition, experiences gained from saddle nose reconstruction may in part be of value for the treatment of nasal septal perforations since implantation of cartilage grafts often represents an essential step in multilayer techniques of closure of nasal septal perforations. Aside from the treatment of orbital complications sinus surgery has been proven beneficial in reducing nasal symptoms and increasing quality of life in patients refractory to systemic treatment.

Keywords: nasal septal perforation; rhinoplasty; saddle nose; sinusitis; systemic disorder.

Table 1. Survey of the literature

Figure 1. Nasal tuberculosis. Region of the nasal choanae (C). Easily-bleeding membranes are visible in the nasopharynx and at the dorsal septum (S).

Figure 2. Closure of a small nasal septal perforation (type A) in a HIV positive patient by cartilage exchange. Demonstration of the small perforation (A). Cartilage resection at the borders of the perforation (B, C). Dorsal septal cartilage graft (D). Closed perforation (E).

Figure 3. Active Wegener’s granulomatosis. Massive crusting and inflammation of the nasal mucosa.

Figure 4. Wegener’s granulomatosis in remission. Large nasal septal perforation (type C). No signs for inflammation or crusting are visible (A). Closure of the perforation by (bilateral) inferior turbinate flap (B) and costal cartilage interposition graft (not shown).

Figure 5. Microscopic Polyangiitis. Prominent vessels at the area II in a patient suffering from recurrent episodes of epsitaxis.

Figure 6. Graduation of nasal septal perforations. Type A: small perforation at the area I (<1 cm in diameter). Type B large perforation at the areas I and II (about 1–1.5 cm in diameter). Type C: Large perforation at the area II and III (>1.5 cm in diameter).

Figure 7. Large nasal septal perforation (type B). Demonstration of the perforation (A). Principle of mobilization of a gingivobuccal pedicled flap (B). Preparation of a gingivobuccal pedicled flap in vivo (C). Closure of the perforation by sutures (D).