**2. Methods and materials**

#### **2.1 Patients**

A retrospective clinical chart review was performed on all of the author's patients who had nasal surgery from January 2016 through December 2018 at the ENT unit of Pantai Hospital Kuala Lumpur (PHKL). All patients had severe nasal obstruction with chronic rhinosinusitis and were followed up for a minimum of 6 months post-surgery. The data revealed that 53 patients out of the 116 patients (45.6%) underwent concurrent open rhinoplasty and ESS by the same surgeon at PHKL. Patients who underwent rhinoplasty and ESS at different sittings (54.4%) were excluded from the study because the SNOT 22 subjective scoring system which was used only for the evaluation of patient symptoms in the concurrent group before and after surgery was sufficient, and therefore the need to compare with patients who underwent rhinoplasty and ESS at different sittings was not necessary. A history of nasal trauma and snoring was documented.

Patients with primary nasal dysfunction and sinus complaints were seen by the same surgeon. All the patients underwent ENT workup which included history, head and neck examination, nasal endoscopy, and CT scans of paranasal sinuses

and were treated with oral antibiotics and topical nasal steroids prior to the CT scan and a full facial analysis including standardized photography.

### **2.2 Evaluation**

The main complaints of the patients prior to surgery were chronic nasal obstruction, postnasal drip, headaches with occasional voice changes, and snoring. External nasal examination was performed to detect a twisted/crooked/saddled nose.

Nasal endoscopy revealed that all these patients had significant anterior septal deviation involving the internal nasal valve, in addition to posterior septal deviation. Nasal endoscopic examination was performed to detect the grading of septal deviations, namely, I, II, III, IV, and V (**Figure 4**), and diseased mucosal or polypoidal tissue (grade 1, 2, 3) involving the paranasal sinuses. If there was evidence of mucopurulent discharge from the paranasal sinuses on nasal endoscopy on admission, the patients were commenced on systemic antibiotics prior to surgery.

#### **2.3 Surgical technique**

All the cases were performed as an inpatient procedure by a one surgeon and two procedure approach under general anesthesia at Pantai Hospital Kuala Lumpur. At the time of induction, all patients received IV antibiotics (ceftriaxone 1 gm) and steroids (dexamethasone 8 mg). The CT scans of the paranasal sinuses were reviewed again in OR prior to performing the surgery. A throat pack was inserted, and the nasal cavity was packed with soaked spacers for vasoconstriction. Infiltration was performed at the nasal dorsum, alar rim, septum, and greater palatine fossa transorally with levobupivacaine (20 cc), adrenaline (0.2 mg), and aqua (1.8 cc). Surgery was initiated with ESS procedure followed by open rhinoplasty approach, but in gross septal deviations, the septoplasty was performed prior to the ESS.

For the open rhinoplasty approach, an inverted transcolumellar V-shaped incision was made, and the SMAS elevated all the way to the dorsum of the nose (**Figure 5**). The domes are divided in the midline, and the upper lateral cartilages released laterally, creating excellent exposure of the septum. Bilateral submucoperichondrial flaps are elevated, exposing the entire cartilaginous and anterior bony septum. The cartilaginous and bony septum is then resected by paramedian

#### **Figure 4.**

*The five areas of the internal nose most commonly involved in nasal septal deviations. Open approach rhinoplasty is indicated in anterior deviations of nasal septum involving areas I, II, and III along with significant internal nasal valve involvement, whereas closed approach is indicated for posterior septal deviations restricted to areas IV and V only.*

**157**

were used for the skin.

**Figure 5.**

*nasal dorsum.*

*Concurrent Rhinoplasty and Endoscopic Sinus Surgery DOI: http://dx.doi.org/10.5772/intechopen.89415*

osteotomy, separating cartilaginous septum from maxillary crest and fracturing bony septum as posterior as possible leaving behind the cribriform plate and sphenoid rostrum. Extracorporeal approach was performed on all patients with gross high septal deviation, which requires complete removal of the entire cartilaginous septum, which is then straightened and returned to the nose. In revision rhinoplasty cases where adequate quadrangular cartilage and septal bone grafts were not available, conchal cartilage graft was harvested. Bilateral spreader grafts are then placed on the dorsal part of the septum. K-wire drill was used to drill multiple holes on the septal bone graft for use as spreader/ columella strut/columella extension graft. Straight 4/0 Monosyn mattress sutures were used to secure the spreader graft. Then lateral osteotomies are performed by external subcutaneous method if required. Nasal spine if deviated more than 30° is gauged out or drilled. Neo-septum with spreader graft is inserted in the nose. Areas of fixation are the caudal end of the nasal bones, upper lateral cartilage, and maxillary crest. A hole is drilled through the nasal bones and the nasal spine and suturing the neo-septum with Monosyn 4/0 sutures. Other required steps like columellar strut, rim grafts, and tip grafts are performed. Soft silicon splints are placed along either side of septum and sutured in place with through-and through 3/0 Monosyn sutures. Curve Monosyn 4/0 and 5/0 were used for tip plasty (transcrural, intercrural, shield graft), dorsal augmentation, caudal augmentation, septum augmentation, and alar rim suturing. Ethicon 6/0 sutures

*Close-up view of open rhinoplasty via a transcolumellar incision and elevation of SMAS all the way to the* 

For the ESS, the mucosa on the lateral wall of the nose and the anterior face of the sphenoid was infiltrated and the diseased sinuses addressed by performing ethmoidectomy, middle meatal antrostomy, sphenoidotomy or frontal sinusotomy. Prior to performing middle meatal antrostomy, an uncinectomy was performed

The nasal and sinus cavities were packed with Nasapore. Steri-Strip was applied

externally on the nasal dorsum along with Denver splints which were removed between 7 and 10 days postoperatively. Nasal cavity suction was performed on the third postoperative day along with the removal of the nasal septal splints and patient sent home the same day. The ESS was performed using a technique adapted

using thru-cut instruments along with a microdebrider.

*Concurrent Rhinoplasty and Endoscopic Sinus Surgery DOI: http://dx.doi.org/10.5772/intechopen.89415*

#### **Figure 5.**

*Rhinosinusitis*

**2.2 Evaluation**

**2.3 Surgical technique**

and were treated with oral antibiotics and topical nasal steroids prior to the CT scan

The main complaints of the patients prior to surgery were chronic nasal obstruction, postnasal drip, headaches with occasional voice changes, and snoring. External

Nasal endoscopy revealed that all these patients had significant anterior septal deviation involving the internal nasal valve, in addition to posterior septal deviation. Nasal endoscopic examination was performed to detect the grading of septal deviations, namely, I, II, III, IV, and V (**Figure 4**), and diseased mucosal or polypoidal tissue (grade 1, 2, 3) involving the paranasal sinuses. If there was evidence of mucopurulent discharge from the paranasal sinuses on nasal endoscopy on admission, the patients were commenced on systemic antibiotics prior to surgery.

All the cases were performed as an inpatient procedure by a one surgeon and two procedure approach under general anesthesia at Pantai Hospital Kuala Lumpur. At the time of induction, all patients received IV antibiotics (ceftriaxone 1 gm) and steroids (dexamethasone 8 mg). The CT scans of the paranasal sinuses were reviewed again in OR prior to performing the surgery. A throat pack was inserted, and the nasal cavity was packed with soaked spacers for vasoconstriction. Infiltration was performed at the nasal dorsum, alar rim, septum, and greater palatine fossa transorally with levobupivacaine (20 cc), adrenaline (0.2 mg), and aqua (1.8 cc). Surgery was initiated with ESS procedure followed by open rhinoplasty approach, but in

gross septal deviations, the septoplasty was performed prior to the ESS.

For the open rhinoplasty approach, an inverted transcolumellar V-shaped incision was made, and the SMAS elevated all the way to the dorsum of the nose (**Figure 5**). The domes are divided in the midline, and the upper lateral cartilages released laterally, creating excellent exposure of the septum. Bilateral submucoperichondrial flaps are elevated, exposing the entire cartilaginous and anterior bony septum. The cartilaginous and bony septum is then resected by paramedian

*The five areas of the internal nose most commonly involved in nasal septal deviations. Open approach rhinoplasty is indicated in anterior deviations of nasal septum involving areas I, II, and III along with significant internal nasal valve involvement, whereas closed approach is indicated for posterior septal* 

nasal examination was performed to detect a twisted/crooked/saddled nose.

and a full facial analysis including standardized photography.

**156**

**Figure 4.**

*deviations restricted to areas IV and V only.*

*Close-up view of open rhinoplasty via a transcolumellar incision and elevation of SMAS all the way to the nasal dorsum.*

osteotomy, separating cartilaginous septum from maxillary crest and fracturing bony septum as posterior as possible leaving behind the cribriform plate and sphenoid rostrum. Extracorporeal approach was performed on all patients with gross high septal deviation, which requires complete removal of the entire cartilaginous septum, which is then straightened and returned to the nose. In revision rhinoplasty cases where adequate quadrangular cartilage and septal bone grafts were not available, conchal cartilage graft was harvested. Bilateral spreader grafts are then placed on the dorsal part of the septum. K-wire drill was used to drill multiple holes on the septal bone graft for use as spreader/ columella strut/columella extension graft. Straight 4/0 Monosyn mattress sutures were used to secure the spreader graft. Then lateral osteotomies are performed by external subcutaneous method if required. Nasal spine if deviated more than 30° is gauged out or drilled. Neo-septum with spreader graft is inserted in the nose. Areas of fixation are the caudal end of the nasal bones, upper lateral cartilage, and maxillary crest. A hole is drilled through the nasal bones and the nasal spine and suturing the neo-septum with Monosyn 4/0 sutures. Other required steps like columellar strut, rim grafts, and tip grafts are performed. Soft silicon splints are placed along either side of septum and sutured in place with through-and through 3/0 Monosyn sutures. Curve Monosyn 4/0 and 5/0 were used for tip plasty (transcrural, intercrural, shield graft), dorsal augmentation, caudal augmentation, septum augmentation, and alar rim suturing. Ethicon 6/0 sutures were used for the skin.

For the ESS, the mucosa on the lateral wall of the nose and the anterior face of the sphenoid was infiltrated and the diseased sinuses addressed by performing ethmoidectomy, middle meatal antrostomy, sphenoidotomy or frontal sinusotomy. Prior to performing middle meatal antrostomy, an uncinectomy was performed using thru-cut instruments along with a microdebrider.

The nasal and sinus cavities were packed with Nasapore. Steri-Strip was applied externally on the nasal dorsum along with Denver splints which were removed between 7 and 10 days postoperatively. Nasal cavity suction was performed on the third postoperative day along with the removal of the nasal septal splints and patient sent home the same day. The ESS was performed using a technique adapted

from Stammberger [12] and Kennedy [13]. The ESS instruments included high-definition Spice monitor, 4 mm endoscopes (0, 30 and 70°), and powered instruments (debrider by Medtronic). IGS was used in revision sinus surgery cases. All patients received postoperative antibiotics and nasal rinse. The one surgeon team performed the postoperative endoscopic debridement and nasal function and documented aesthetic alterations with standardized postoperative photography.
