**2.4 Data collection**

The medical charts of included patients were retrieved for analysis and demographic data obtained (**Table 1**). The medical and surgical history, presenting complaints and physical and endoscopic examination results, was documented. The details of the rhinoplasty and sinus surgery subtype procedures are listed in **Tables 2** and **3**, respectively. Patient follow-ups were obtained with standardized questionnaires (SNOT 22) of presenting complaints, satisfaction with surgical experience, and self-evaluation of aesthetic outcome.


**159**

*Indian\**

**Table 1.**

*Revision cases*

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

26 I 25 F SP, SprG, SG,

30 C 23 M SP, SprG, CEG,

37 C 50 M SP, SprG, CEG,

38\* I 23 M SP, SprG, CS, SG,

44 I 23 F SP, SprG, SG, O,

48 M 27 M SP, SprG, CEG,

52 I 18 F SP, SprG, CEG,

*Demographics of 53 patients who underwent concurrent rhinoplasty and ESS.*

31 M 25 F SP, SprG, CEG, SG TR, E, MMA,

35 I 22 M SP, SprG, SG TR, E, MMA,

41 I 28 F SP, SprG, SG, CSR TR, E, MMA,

**Age Sex Open rhinoplasty** 

**(ORP) procedure**

CSR, O

37 M SP, SprG, SG, O TR, E, MMA,

25 C 40 F SP, SprG, CEG, SG TR, E, MMA 169 105

28 M 26 F SP, SprG, CEG, SG TR, E, MMA 189 160 29 I 31 M SP, SprG, CS, SG TR 148 140

SG, O

32 M 36 F SP, SprG, CEG, SG TR, E, MMA 197 100 33 I 41 F SP, SprG, CS, SG TR 154 80 34 M 25 F SP, SprG, CEG, SG TR, E, MMA 176 130

36 I 16 M SP, SprG, SG TR 160 80

SG, O

O, HR, CCG

39 I 33 M SP, SprG, CEG, SG TR, E, MMA 191 115 40 Indonesia 38 F SP, SprG, CEG, SG TR 169 75

42 C 52 F SP, SprG, CEG, SG TR, E, MMA 212 95 43 C 30 F SP, SprG, CEG, SG TR 172 85

HR

SG, O

SG, O, HR

53 Iran 35 M SP, SprG, CS, SG TR, E, MMA 197 120 *TR, turbinate reduction; SP, septoplasty; Spr G, spreader graft; CEG, columella extension graft; SG, shield graft; HR, hump reduction; CS, columella strut; CCG, conchal cartilage graft; CSR, caudal septal resection; E, ethmoidectomy; MMA, middle meatal antrostomy; Sph, sphenoidotomy; FS, frontal sinusotomy; M, Malay; C, Chinese; I,* 

49 Indonesia 32 M SP, SprG, CEG, SG TR,E 193 105 50 M 28 M SP, SprG, CEG, SG TR, E, MMA 176 115 51 I 18 M SP, SprG, CS, SG TR 163 95

45 I 36 M SP, SprG, CS, SG TR 97 110 46 M 41 F SP, SprG, CEG, SG TR 163 75 47 C 17 M SP, SprG, CEG, SG TR, E, MMA 191 105

**ESS procedure Duration** 

TR, E, MMA, Sph

FS, Sph

TR, E, MMA, FS

Sph

Sph

TR, E, MMA, FS, Sph

FS

TR, E, MA, FS, Sph

TR, E, MMA, FS, Sph

**(minutes)**

191 180

261 245

253 215

214 120

187 110

267 210

189 90

265 220

259 250

TR, E, MMA 181 105

TR, E, MMA 183 120

**Blood loss (ml)**

**Race/country of origin**

Kingdom

**Patient number**

27 United


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

*Rhinosinusitis*

**2.4 Data collection**

aesthetic outcome.

**Race/country of origin**

1 M 34 F SP, SprG, CEG

3 M 39 F SP, SprG, CEG,

6\* C 50 F SP, SprG, CEG SG,

10 M 32 M SP, SprG, CEG

18\* M 55 M SP, SprG, CEG,

9 I 32 F SP, SprG, SG, CSR TR, E, MMA,

**Patient number**

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

The medical charts of included patients were retrieved for analysis and demographic data obtained (**Table 1**). The medical and surgical history, presenting complaints and physical and endoscopic examination results, was documented. The details of the rhinoplasty and sinus surgery subtype procedures are listed in **Tables 2** and **3**, respectively. Patient follow-ups were obtained with standardized questionnaires (SNOT 22) of presenting complaints, satisfaction with surgical experience, and self-evaluation of

**(ORP) procedure**

SG, O

SG, O

O, CCG

SG, O

SG, O

 I 32 F SP, SprG, SG TR, E, MMA 171 110 M 40 F SP, SprG, CEG, SG TR, E, MMA 154 85 I 25 M SP, SprG, CS, SG TR 159 85 I 25 F SP, SprG, SG TR 167 105 I 29 M SP, SprG, SG TR, E, MMA 143 115 C 31 F SP, SprG, CEG, SG TR, E, MMA 156 95

 I 23 F SP, SprG, SG TR 141 90 Australia 45 F SP, SprG, SG TR, E, MMA 185 100 I 32 F SP, SprG, CS, SG TR, E, MMA 195 95 M 18 M SP, SprG, CEG, SG TR, E 190 75 C 22 F SP, SprG, CEG, SG TR, E, MMA 184 110 C 40 F SP, SprG, CEG, SG TR 164 85 M 28 M SP, SprG, CEG, SG TR, E, MMA 168 90

2 Canada 54 F SP, SprG, SG TR 145 115

4 I 36 M SP, SprG, SG, HR TR 148 110 5 I 32 F SP, SprG, CS, SG TR, E, MMA 179 90

7 C 26 F SP, SprG, CEG SG TR 152 80 8 M 30 F SP, SprG, CEG SG TR, E, MMA 177 85

**ESS procedure Duration** 

TR, E, MMA, FS

Sph

TR, E, MA, FS, Sph, CCG

**(minutes)**

287 235

211 105

277 240

TR, E, MMA 179 95

TR, E, MMA 181 115

TR, E, MMA 189 120

**Blood loss (ml)**

**Age Sex Open rhinoplasty** 

aesthetic alterations with standardized postoperative photography.

**158**

*TR, turbinate reduction; SP, septoplasty; Spr G, spreader graft; CEG, columella extension graft; SG, shield graft; HR, hump reduction; CS, columella strut; CCG, conchal cartilage graft; CSR, caudal septal resection; E, ethmoidectomy; MMA, middle meatal antrostomy; Sph, sphenoidotomy; FS, frontal sinusotomy; M, Malay; C, Chinese; I, Indian\* Revision cases*

#### **Table 1.**

*Demographics of 53 patients who underwent concurrent rhinoplasty and ESS.*


#### **Table 2.**

*Summary of endoscopic sinus subtype procedures performed on 53 patients who underwent concurrent two procedural approaches.*


#### **Table 3.**

*Summary of rhinoplasty subtype procedures performed on 53 patients who underwent concurrent two procedural approaches.*

## **3. Results**

Between January 2016 and December 2018, 53 patients underwent rhinoplasty combined with endoscopic sinus surgery (ESS). The demography of the patients is listed in **Table 1**. There were 31 females and 22 males with age ranging from 16 to 55 years with a mean of 31.8 years. There were three referred revision cases where rhinoplasty [1] and septoplasty [2] were performed elsewhere. All patients had open approach rhinoplasty. The average operative time was 45 minutes for endoscopic sinus surgery and 141.20 minutes for rhinoplasty. The average operating time for the concurrent procedure was 186.20 minutes, and average blood loss was 121.4 ml. Out of the 53 patients, there were 15 Malays, 11 Chinese, and 21 Indians, and the remaining 6 were foreigners (one each from Australia, Canada, Iran, and the United Kingdom and two from Indonesia). Thirty-eight (71,6%) of the 53 patients had a history of chronic snoring and 27 (50.9%) history of nasal trauma.

Regarding the ESS, the most common procedure performed was septoplasty and turbinate reduction in all patients, followed by ethmoidectomy (71.7%), middle meatal antrostomy (67.9%), sphenoidotomy (16.9%), and frontal sinusotomy (15.1%). Majority of the patients had extensive mucosal disease requiring sinus surgery.

Regarding the rhinoplasty procedures, the most common aesthetic procedure was spreader graft and shield graft in all patients followed by columella extension graft (54.7%), osteotomy (24.5%), columella strut (11.9%), hump reduction (7.5%) caudal septal resection, and conchal cartilage graft (5.6%). It is of interest to note that 53 patients had some type of cartilage graft performed (spreader graft, shield graft, columellar extension graft, caudal septal resection, columella strut, and conchal cartilage graft). Pictures of spreader and shield grafts are illustrated in **Figures 6** and **7**. All patients were followed up for a minimum of 6 months of post-surgery at the time of this report. All patients reported an improvement in

**161**

**4. Discussion**

**Figure 7.**

*Close-up view of shield graft augmentation tip plasty.*

**Figure 6.**

*of twisted nose.*

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

their sinus symptoms and were adequately satisfied with their nasal appearance. No revision rhinoplasty or ESS was performed on this group at the time of reporting. There were no major complications noted in this study. There were minor complications reported which were mainly delayed wound healing [2], minor irregularities of the nasal dorsal skin lining [2], alar asymmetry [2], and pinching of the nose [1]. None of the patients were interested in further surgical intervention at that moment in time.

*Picture showing spreader graft sandwiched between the septum just before mattress sutures are applied in a case* 

In the population, there are patients with cosmetic nasal concerns who will also have functional problems (nasal obstruction and/or sinus problems) which should be *Concurrent Rhinoplasty and Endoscopic Sinus Surgery DOI: http://dx.doi.org/10.5772/intechopen.89415*

#### **Figure 6.**

*Rhinosinusitis*

**Table 2.**

*procedural approaches.*

**3. Results**

*procedural approaches.*

**Table 3.**

trauma.

Between January 2016 and December 2018, 53 patients underwent rhinoplasty combined with endoscopic sinus surgery (ESS). The demography of the patients is listed in **Table 1**. There were 31 females and 22 males with age ranging from 16 to 55 years with a mean of 31.8 years. There were three referred revision cases where rhinoplasty [1] and septoplasty [2] were performed elsewhere. All patients had open approach rhinoplasty. The average operative time was 45 minutes for endoscopic sinus surgery and 141.20 minutes for rhinoplasty. The average operating time for the concurrent procedure was 186.20 minutes, and average blood loss was 121.4 ml. Out of the 53 patients, there were 15 Malays, 11 Chinese, and 21 Indians, and the remaining 6 were foreigners (one each from Australia, Canada, Iran, and the United Kingdom and two from Indonesia). Thirty-eight (71,6%) of the 53 patients had a history of chronic snoring and 27 (50.9%) history of nasal

*Summary of rhinoplasty subtype procedures performed on 53 patients who underwent concurrent two* 

Septoplasty (SP) 53 (100%) Turbinate reduction (TR) 53 (100%) Ethmoidectomy (E) 38 (71.7%) Middle meatal antrostomy (MMA) 36 (67.9%) Sphenoidotomy (Sph) 9 (16.9%) Frontal sinusotomy (FS) 8 (15.1%)

*Summary of endoscopic sinus subtype procedures performed on 53 patients who underwent concurrent two* 

Spreader graft (SprG) 53 (100%) Shield graft (SG) 53 (100%) Columella extension graft (CEG) 29 (54.7%) Osteotomy (O) 13 (24.5%) Columella strut (CS) 9 (16.9%) Hump reduction (HR) 4 (7.5%) Caudal septal resection (CSR) 3 (5.6) Conchal cartilage graft (CCG) 3 (5.6)

Regarding the ESS, the most common procedure performed was septoplasty and turbinate reduction in all patients, followed by ethmoidectomy (71.7%), middle meatal antrostomy (67.9%), sphenoidotomy (16.9%), and frontal sinusotomy (15.1%).

Regarding the rhinoplasty procedures, the most common aesthetic procedure was spreader graft and shield graft in all patients followed by columella extension graft (54.7%), osteotomy (24.5%), columella strut (11.9%), hump reduction (7.5%) caudal septal resection, and conchal cartilage graft (5.6%). It is of interest to note that 53 patients had some type of cartilage graft performed (spreader graft, shield graft, columellar extension graft, caudal septal resection, columella strut, and conchal cartilage graft). Pictures of spreader and shield grafts are illustrated in **Figures 6** and **7**. All patients were followed up for a minimum of 6 months of post-surgery at the time of this report. All patients reported an improvement in

Majority of the patients had extensive mucosal disease requiring sinus surgery.

**160**

*Picture showing spreader graft sandwiched between the septum just before mattress sutures are applied in a case of twisted nose.*

**Figure 7.** *Close-up view of shield graft augmentation tip plasty.*

their sinus symptoms and were adequately satisfied with their nasal appearance. No revision rhinoplasty or ESS was performed on this group at the time of reporting.

There were no major complications noted in this study. There were minor complications reported which were mainly delayed wound healing [2], minor irregularities of the nasal dorsal skin lining [2], alar asymmetry [2], and pinching of the nose [1]. None of the patients were interested in further surgical intervention at that moment in time.

### **4. Discussion**

In the population, there are patients with cosmetic nasal concerns who will also have functional problems (nasal obstruction and/or sinus problems) which should be fully evaluated. Moreover, patients with functional nasal problems would like a cosmetic nasal improvement (**Figures 8, 9**, and **10**). It is meaningful that patients who would benefit from rhinoplasty and ESS would wish to combine the two procedures which would save patients time, money, and inconvenience. Advances in powered sinus instrumentation have made combining rhinoplasty and ESS more attractive. In 1991, Sheman and Matarasso [15] first reported combining rhinoplasty and ESS, and since then various authors have reported a bigger series demonstrating the safety and efficacy of combining these two procedures [16–21].

Since the main complaint on presentation was chronic nasal obstruction (DNS with enlarged turbinates) with rhinosinusitis, all the patients had septal surgery with turbinate reduction. The CT scan of the paranasal sinuses performed on all the patients showed evidence of involvement of more than one paranasal sinus; the ESS was performed on more than one sinus. The most common sinuses involved were the ethmoid and the maxillary sinuses, with less incidence of involvement of sphenoid and frontal sinuses. Since all the patients presented with internal nasal valve problems, all the patients had spreader with shield graft performed.

Since all patients had caudal septal deviation with narrow nasal valve, spreader graft was performed on all patients. Only 24.5% of patients had mid-vault deformity which required osteotomy.

Powered instrumentation combining suction, irrigation, debridement, and cautery reduces surgical steps, operative time, and blood loss. IGS is a valuable

**Figure 8.**

*Pre (A1 and A2) and postoperative (A3 and A4) pictures of patient no. 38 who presented with twisted nose, prominent nasal hump, and CRS.*

**163**

**Figure 9.**

*pseudo-hump nasal hump, and CRS.*

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

instrument used for anatomic confirmation especially in revision cases. Absorbable sinus packing has increased patient comfort. Advances in ESS instrumentation have

*Pre- (B1 and B2) and postoperative (B3 and B4) pictures of patient no. 13 who presented with crooked nose,* 

technique illustrates the overall safety and efficacy of combining the two procedures. This study shows that the ESS using powered instrumentation is not too time-consuming, on average taking about 45 minutes in this study compared to 50 minutes in other reported cases [13]. Total blood loss for the combined procedure was about three times more (121 cc) in our study compared to blood loss in other studies (40 cc) [21] which could likely be due to the more extensive paranasal sinus mucosal disease involvement. The average operating time for the concurrent procedure was 186.20 minutes compared to 110 minutes in other reports [22] which could likely be due to time-consuming remodeling utilizing autografts. All the patients had some type of cartilage grafting with no evidence of infection, extrusion, malposition, or resorption since autologous grafts were used in all 53 patients. Minor complications like erythematous columellar incisions were treated aggres-

This addition of 53 cases of rhinoplasty with ESS to the literature by one surgeon

made the procedure faster, safer, precise, and comfortable.

sively with a course of oral antibiotics.

**Figure 9.**

*Rhinosinusitis*

fully evaluated. Moreover, patients with functional nasal problems would like a cosmetic nasal improvement (**Figures 8, 9**, and **10**). It is meaningful that patients who would benefit from rhinoplasty and ESS would wish to combine the two procedures which would save patients time, money, and inconvenience. Advances in powered sinus instrumentation have made combining rhinoplasty and ESS more attractive. In 1991, Sheman and Matarasso [15] first reported combining rhinoplasty and ESS, and since then various authors have reported a bigger series demonstrating the safety and

Since the main complaint on presentation was chronic nasal obstruction (DNS with enlarged turbinates) with rhinosinusitis, all the patients had septal surgery with turbinate reduction. The CT scan of the paranasal sinuses performed on all the patients showed evidence of involvement of more than one paranasal sinus; the ESS was performed on more than one sinus. The most common sinuses involved were the ethmoid and the maxillary sinuses, with less incidence of involvement of sphenoid and frontal sinuses. Since all the patients presented with internal nasal valve problems, all the patients had spreader with shield graft performed.

Since all patients had caudal septal deviation with narrow nasal valve, spreader graft was performed on all patients. Only 24.5% of patients had mid-vault defor-

Powered instrumentation combining suction, irrigation, debridement, and cautery reduces surgical steps, operative time, and blood loss. IGS is a valuable

*Pre (A1 and A2) and postoperative (A3 and A4) pictures of patient no. 38 who presented with twisted nose,* 

efficacy of combining these two procedures [16–21].

mity which required osteotomy.

**162**

**Figure 8.**

*prominent nasal hump, and CRS.*

*Pre- (B1 and B2) and postoperative (B3 and B4) pictures of patient no. 13 who presented with crooked nose, pseudo-hump nasal hump, and CRS.*

instrument used for anatomic confirmation especially in revision cases. Absorbable sinus packing has increased patient comfort. Advances in ESS instrumentation have made the procedure faster, safer, precise, and comfortable.

This addition of 53 cases of rhinoplasty with ESS to the literature by one surgeon technique illustrates the overall safety and efficacy of combining the two procedures. This study shows that the ESS using powered instrumentation is not too time-consuming, on average taking about 45 minutes in this study compared to 50 minutes in other reported cases [13]. Total blood loss for the combined procedure was about three times more (121 cc) in our study compared to blood loss in other studies (40 cc) [21] which could likely be due to the more extensive paranasal sinus mucosal disease involvement. The average operating time for the concurrent procedure was 186.20 minutes compared to 110 minutes in other reports [22] which could likely be due to time-consuming remodeling utilizing autografts. All the patients had some type of cartilage grafting with no evidence of infection, extrusion, malposition, or resorption since autologous grafts were used in all 53 patients. Minor complications like erythematous columellar incisions were treated aggressively with a course of oral antibiotics.

#### *Rhinosinusitis*

#### **Figure 10.**

*Pre- (C1 and C2) and postoperative (C3 and C4) pictures of patient no. 26 who presented with twisted nose, pseudo-nasal hump, and CRS post-trauma.*

A review of 268 rhinoplasties between 1997 and 2001 demonstrated 11 cases with concurrent surgery, and there were no complications noted in this study [17]. Furthermore, the authors mention a case report of a 22-year-old patient who underwent a septorhinoplasty and ESS on an outpatient basis at another institution and developed edema over the nose, cheek, glabella, and forehead regions with fever. A CT scan of paranasal sinuses showed evidence of opacification of the frontal sinuses with dehiscence of nasal bones which responded to intravenous medication and frontal trephination. Herzon in 1971 reported a 12% incidence of bacteremia in patients undergoing nasal septal surgery requiring nasal packing [23]. In 1978, Todd et al. reported the first case of toxic shock syndrome (TSS) [24].Four years later the first case of TSS after septorhinoplasty was reported [25].

Most authors agree that performing the sinus surgery first allows the surgeon to determine if there is ongoing rhinosinusitis. Millman B who performs combination rhinoplasty with ESS recommends not proceeding with rhinoplasty if there are signs of infection [17].

There have been only 4 reported cases of MRSA associated postoperative complications following septorhinoplasty reported in the literature across all specialities [26]. Patients who are susceptible to MRSA infections may also be at higher risk for nasal colonization, and this includes elderly patients, patients recently hospitalized or treated in a rehabilitation center, and health-care workers. Few cases of MRSA infection following septorhinoplasty have been reported in the literature. Elimination

**165**

**Author details**

Balwant Singh Gendeh

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

**5. Conclusion**

of nasal colonization is a major step in preventing these infections, and preoperative systemic antibiotic use should be considered, especially in revision cases [27].

Most of the sinus symptoms resolved postoperatively with 47 (88.6%) of 53 patients describing their improvement as significant. Fifty (94.3%) of 53 patients

The author has reasonably good results combining rhinoplasty and ESS, and the benefits of these advances are illustrated by a review of the literature with good results (functional and cosmetic) and minimal complications. Extracorporeal approach was performed on all patients with gross high septal deviation. All the patients had some type of cartilage grafting with no evidence of infection, extrusion, malposition, or resorption since all the patients had autologous grafts inserted. Minor complications like erythematous columellar incisions were treated aggressively with a course of oral antibiotics. Advances in rhinoplasty and sinus surgery technique and equipment have made this one surgeon combined procedure safe and

stated that they would recommend the concurrent procedure.

cost-effective with good results in selected patients.

Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

\*Address all correspondence to: bsgendeh@gmail.com

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

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

of nasal colonization is a major step in preventing these infections, and preoperative systemic antibiotic use should be considered, especially in revision cases [27].

Most of the sinus symptoms resolved postoperatively with 47 (88.6%) of 53 patients describing their improvement as significant. Fifty (94.3%) of 53 patients stated that they would recommend the concurrent procedure.
