Cartilage or Fascia Implanting To The Inferior Meatus For Nasal Hyperventilation

Inferior Meatus Augmentation With Rib Cartilage Procedure

Empty nose syndrome and intranasal air flow dynamics are still controversial and unknown issues. In cases where the intranasal airway is less than normal (nasal hypoventilation), patients experience "nasal congestion" and "feeling of low airflow from the nose" as a result of insufficient intake of air from the nose (increased nasal resistance). On the contrary, as a result of excessive reduction or resection of the "turbinates", which are mainly responsible for the air resistance in the nose, abnormally decreased nasal airway resistance, increased intranasal airflow velocity (nasal hyperventilation), and changes in intranasal aerodynamics occur. In this second case, in addition to symptoms such as accelerated and almost linear airflow from the nose, drying of the mucous membrane in the nose, affected free nerve endings, dryness in the nasal passages and dryness in the secretions, similarly, the insufficiency of the air taken from the nose, "nasal air deficiency", the nasal anatomy has been changed to a high degree. and even a "suffocating sensation" occurs in patients whose intranasal airway is very enlarged. Unfortunately, the controversial issue on this issue and causing differences of opinion among physicians is why nasal air is not sufficient in patients with "open nasal airway or narrow nasal air passage". Sometimes, when the intranasal airway is quite wide, a "psychiatry consultation" may even be requested for patients who have the expression "the air I get from the nose is not enough"; Unnecessary "turbinate radiofrequency reduction" operation can be performed for the second time.

Nasal hyperventilation is less severe than the empty nose syndrome, but is also a condition that occurs due to accelerated intranasal airflow due to the altered nasal anatomy.

Descriptive Explanation of the Cotton Test in Patients Suspected of Empty Nose Syndrome (ENS) and Nasal Hyperventilation

In this article, I would like to talk about a patient who had two previous septoplasty and turbinate radiofrequecy reduction operations with complaints of "pain in the nose", "coldness in the nose while breathing", "not enough air taken from the nose" and "dryness in the nose". When the patient applied to different clinics, it was emphasized that the intranasal airway was adequate and there was a nasal septum perforation with a diameter of several mm in the lower posterior part of the nasal septum. It was emphasized that if the air taken from the nose is not enough, turbinate reduction can be done again. Here, although distinctive and controversial, the "cotton test" or "cotton insertion into the nose" test can help in diagnosis. Should the patient's nose be made wider, or should the patient's nasal passage be narrowed?

Cotton Test

In patients with suspected empty nose syndrome and nasal hyperventilation, cotton can be placed inside the nose to investigate changes in the air passages and their effects on the patient's complaints. We usually recommend that our patients place cotton in a way that will not completely block the nostril but will narrow certain areas inside the nose. As seen in the photo above, a large and round cotton ball can completely block the nasal cavity. Therefore, patients are exposed to the effect of completely stopping and disabling the nose, rather than changing the nasal airflow. In other words, in order to understand which intranasal area is most suitable for cartilage implantation, it is ideal to prepare a cylindrical cotton ball, as on the right side of the photo above, "without completely closing the nose", and place it inside the nose, in the areas immediately at the entrance of the nostrils. It is important to cover the cotton with Vaseline or eye ointment so that it does not dry out the mucosa inside the nose or cause local trauma. In addition, small cotton balls pushed backwards are not suitable due to the risk of aspiration. One of the feedbacks from my patients with ENS stated that spongostan (spongel) instead of cotton test can give a more accurate result because it is less irritating to the nasal mucosa and softer, but it is more expensive.

The cotton ball getting stuck in the nasal cavity and acting as a foreign body, possibly leading to inflammation or infection.
In the image above, a cotton ball lodged in the left nasal cavity results in foreign body and infection, inflammation, and secretions. The patient believed she had developed empty nose syndrome and subsequently atrophic rhinitis. The cotton test technique here is incorrect. As shown in the image below, a 2-3 cm long, cylindrical cotton ball coated with petroleum jelly or eye ointment should be prepared. Only about half of it should be inserted into the nose and removed after a few hours. The patient was unaware of the cotton ball's entry and forgot about it. Inflammatory discharge is related to a foreign body reaction.

In the image above, the patient has placed the cotton ball inside the nose, completely covering both nasal cavities. While we naturally need nasal air, completely closing the nose can be intolerable for many patients for a long time. The purpose of the cotton test is to determine whether there is a limited degree of narrowing of the nasal air passage and the associated symptom relief. This is intended as a guide for cartilage implants or filler injections to narrow the nasal airway. As directed by your doctor, it would be appropriate to prepare a 6-8 mm thick cotton ball, cylindrical and coated with Vaseline/eye ointment, as shown in the visual description above, so that half of it can be inserted into the nose.

The image on the side is a photo drawn by my patient with septum perforation and empty nose syndrome. My patient drew a visual explaining the technical details by performing a cotton test and preparing thick cotton on one side and thin cotton on the other. Septum perforation closure and bilateral inferior meatal augmentation with cartilage implantation were planned for the patient.

The patient's temporal fascia and rib cartilage were used.

"Inferior meatus augmentation" can be planned if the patient prepares a cotton ball impregnated with antibiotic eye ointment and regularly places it in the nose for a few hours (without closing the nose completely), if the patient's complaints decrease when the nose is narrowed. Contrary to this; If the complaints increase when dilator nasal strips are used, it can be considered that there is "nasal hyperventilation". Normally, there should be a distance of several mm between the inferior turbinate and the nasal septum. The patient, whose photograph I have shared with you below, had abnormally small inferior turbinates and when he narrowed this area by placing cotton in the lower part of the intranasal airway, rib cartilage implantation was planned in the inferior meatus for the patient, as his complaints subsided.

Cartilage graft augmentation of the inferior meatus - surgical procedure details

This procedure can be performed under local or general anesthesia. General anesthesia was preferred in our patient. After local anesthetic infiltration, a submucosal tunnel was opened after incision in the inferior meatus and nasal floor. A 1x3 cm cartilage graft obtained from irradiated costal cartilage obtained from a cadaver was placed near the lower part of the nasal septum and the nasal floor. The mucosal incision was sutured with 6/0 vicryl. Bleeding was controlled, the operation was terminated by placing spongos from which antibiotics were obtained.

Photo descriptions

In the 3 collage photographs below, the upper photograph showing a larger-than-normal air passage and a considerably smaller-than-normal inferior turbinate in the left nasal cavity, and the narrowed air passage 2 months later, after the inferior meatus augmentation, the protrusion of the inserted cartilage graft is seen. In the same way, the nasal septum perforation with a diameter of several mm is visible in the upper photo, while it can be seen to be completely closed in the lower photo.

Submucosal Temporalis Fascia Implantation (Inferior Meatus Augmentation With Fascia Procedure  - Nasal Floor Implantation) and Lateral Nasal Wall Temporalis Fascia Implantation

The upper photograph in the adjacent and below images was obtained from an endoscopic examination of the nasal cavity of a patient who presented with crusting, dryness, and bleeding inside the nose after a previous rhinoplasty performed at a different clinic. The patient's left inferior turbinate was completely resected. A dry and red area is observed in the anterior portion of the middle turbinate due to rapid air exposure. The nasal mucosa is unhealthy, bleeding, and crusty. A temporalis fascia graft, taken from both sides, was placed submucosally in several layers over the left nasal cavity and lateral nasal wall, and the mucosal incision was sutured. In the lower photograph in the adjacent image, the red arrows indicate the "Inferior Meatus Augmentation" and "Lateral Nasal Wall Temporalis Fascia Implantation" areas.

Submucosal Temporalis Fascia Implantation (Inferior Meatus Augmentation With Fascia Procedure  - Nasal Floor Implantation) and Lateral Nasal Wall Temporalis Fascia Implantation

You can watch the nasal mucosa image of the above patient one month later in the video below >>

In which patients can this procedure be performed?

Surgical narrowing of the intranasal air passage may be appropriate in patients whose turbinates are not completely removed and their complaints are reduced by cotton test. Modified Young or Young's Operation has also been described in patients whose turbinates have been completely removed. Again, procedures can be performed to close the nasal septum perforations, which may cause abnormal acceleration in the intranasal air passage.

Patient Selection for Cartilage Implantation to Inferior Meatus Augmentation Operation

Although it is not easy to tell which patients are suitable for cartilage implantation of the inferior meatus; As a simple application, if the patients state that they are satisfied after the small balls of pauk impregnated with eye ointment are placed into the nose, or if the patients state that a positive effect is obtained when the hyaluronic acid filler is injected into the existing turbinate tissue (usually they say this within a few weeks), the intranasal airflow cartilage implantation can be planned in order to narrow the pathways.

In the links below, you can find detailed information about the definition of nasal hyperventilation, its symptoms, the functions of turbinates, and what is wrong turbinate overreduction or turbinate reduction.

Cost of Cartilage Implantation For Nasal Hyperventilation in Istanbul

In this procedure we can use the ear or rib cartilage (patien's own cartilage or cadaveric cartilage). The cost is about 3500-4500 US Dollars according to the hospitals. Prices may increase in luxury hospitals.

Similar links >> Perfect Physiology of the Nose - Airflow Properties / Modified Young Procedure and Septum Correction Surgery / Which Patients With Nasal Hperventilation May Benefit From Turbinate Filler Injection!

Source links >> Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling / Long-Term Outcomes of Inferior Meatus Augmentation Procedure to Treat Empty Nose Syndrome

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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