ABSTRACT
The nose acts as a physiologic airway resistor, accounting for around 50% of total
airway resistance. Adequate nasal resistance is essential not only for correct functioning
of the nose but to ensure normal pulmonary physiology. Pathological nasal resistance
is determined by alterations in the shape and volume of the nasal cavities that singly
or in association disrupt nasal aerodynamics, a condition that will present mainly
in the form of obstructive disorders. The authors advise against considering nasal
cavity surgery simply as surgery of the nasal septum. Nasal surgery should be addressed
to normalizing the geometry of the nasal cavities in order to restore physiologic
nasal resistance. Surgical procedures may be classified as follows: (1) surgery of
the medial wall; (2) surgery of the lateral wall; and (3) surgery of the valve area.
Septal surgery is systematically performed by the authors using the maxilla-premaxilla
approach (MPA). Functional correction of the septum combines mobilization and/or removal
of any deranged portion of the bony and/or cartilaginous septum, followed by reconstruction
of the septum support, preferably using autogenous septal grafts. When reconstructing
the medial wall, great care must be taken with the most important portion of the septum,
i.e., the dorso-caudal margin and the cartilaginous elements. We have called this
procedure Functional Osteocartilaginous Reconstruction of the Nasal Septum (FORNS).
Obstructive swelling of the turbinates is one of the most common causes of nasal obstruction
as it alters the shape and reduces the volume of the nasal cavities causing an exponential
increase in nasal resistance. With regard to surgery of the lateral wall, the authors
firmly believe that mutilating procedures like total inferior turbinectomy can in
no way be considered functional surgery of the turbinates. On the contrary, aim of
lateral wall functional surgery is not simply to widen the airway, but rather to restore
normal aerodynamic contours to the lateral wall in order to prevent turbulence, a
phenomenon which will cause increased nasal resistance. To do this, the authors make
systematic use of Conservative Submucosal Turbinoplasty (CST). The procedure is designed
especially to treat the sub-mucosa since this is the main focus of anatomo-pathological
alterations.
Nasal valve surgery is one of the most high-risk surgical procedures since scarring,
stiffening, or loss of structural support may cause severe and even irreversible damage.
Any surgery of the valve area should therefore carry minimum risk of respiratory complications
and aesthetic defects. In the light of these principles, the authors propose a valve
area correction technique carried out exclusively through the hemitransfixion incision.
This approach affords wide access to the whole valve area, allowing the rhino-surgeon
to perform a range of corrections on the anatomic sub-units constituting the nasal
valve complex. This same approach can be used to place various grafts.
The authors propose a “tailored surgery to normalize the nasal resistances,” i.e.,
a systematic surgery to reshape the volume of the various segments of the nasal chambers
by repositioning as close to normalcy as possible the disrupted skeletal framework
and recontouring streamlined nasal walls.
