Intraseptal Fascia and Donor Cartilage Grafting in Empty Nose Syndrome: A Case with Endoscopic Documentation
ENS After Aggressive Turbinate Resection: Endoscopic Findings and Nasal Septum Thickening - Implantation with Fascia and Donor Cartilage
A patient who had previously undergone near-total left inferior turbinate resection (with only the tail portion of the left inferior turbinate remaining as remnant), endoscopic sinus surgery (partial resection of the left middle turbinate and medial wall resection of the left maxillary sinus), and right inferior turbinate reduction (partial resection) at a different clinic, presented to our clinic with symptoms of empty nose syndrome (ENS). The patient described a severe feeling of cold air in the left nasal cavity, sticky secretions, dryness in the pharynx, and a feeling of air hunger. The right nasal passage was slightly narrower than the left. Following cotton swab trials, nasal septum implantation was planned. Although easy to describe, it was a highly complex surgical procedure. The details of the procedure are described below.
Empty Nose Syndrome Case: Septal Thickening with Donor Cartilage and Fascia Grafting - Visual Descriptions
Left Nasal Cavity
.jpg)
Image 1: Endoscopic examination of the patient revealed that a large portion of the left inferior turbinate was resected, with only the tail portion remaining as a remnant turbinate. Partial resection of the left middle turbinate and a portion of the medial wall of the left maxillary sinus were also observed. The inside of the maxillary sinus was directly visualized, and even a ball of secretion and sticky secretions were seen extending towards the sinus. Two red double-headed dashed arrows indicate an abnormal open air passage.
Image 2: During cotton swab tests, a cotton ball slightly larger than 1 cm was initially placed in the upper middle part of the nasal cetum in the left nasal cavity. However, the patient felt better airflow when cotton was placed in the area marked with a yellow oval circle. The patient stated that they had been performing cotton swab tests in this area for several months and that their symptoms decreased when cotton balls of this size were placed in this yellow-marked area or when using a long cotton swab. Intraseptal implantation was planned if possible in the yellow-marked area. When cold light was applied to the patient's other nasal passage, we assessed the presence of septal bone and cartilage tissue in this area, indicating that the septum was not very thin. Furthermore, palpation with an elevator revealed the presence of septal cartilage-bone structure in this area.
Image 3: A fascia graft was created from temporal fascia obtained after a skin incision in the patient's right temple region. The graft was folded over itself to create a volume similar to a cotton ball. An incision was made in the septal area indicated by two green dashed arrows. Submucoperichondrial dissection was performed, and the fascia graft was placed in the area shown in the previous image (yellow area) and secured to the septum with 5/0 PDS. Additionally, two donor cartilage grafts, each 5x8 mm in diameter, were placed intraseptally and secured to the septum with 5/0 PDS. The upper part of the septum was sutured transseptally with 4/0 rapid vicryl sutures. The incision site was sutured and an internal silicone splint was inserted.
Image 4: The area where the left nasal passage narrowed after intraseptal implantation (septum thickening) is indicated by red arrows in Image 1; this area is also indicated by two pink double-headed dashed arrows. It is easily seen that the distance between the septum and the lateral nasal wall at the same level has narrowed. No nasal septum perforation was detected.
Right Nasal Cavity
.jpg)
Image 1: Endoscopic examination of the patient revealed a small right inferior turbinate, a slightly larger-than-normal passage, and dry nasal mucosa. The patient reported a reduction in symptoms when placing cotton swabs in the posterior part of the septum. The presence of turbinate bullosa in the right middle turbinate is considered a normal anatomical tissue narrowing the nasal cavity on this side.
Image 2: In cotton swab tests, a cotton ball approximately 1 cm in size was first placed in the posterior and inferior part of the nasal septum in the right nasal cavity. The patient observed improved airflow. The patient stated that they had been performing cotton swab tests in this area for several months and that their symptoms decreased when using a long cotton swab. This area was quite posterior for graft implantation, making transept suturing impossible due to the bony septum (vomer).
Image 3: A graft was prepared from the temporal fascia in several layers. The graft was pre-prepared as a bait using several 5/0 PDS sutures. Submucoperichondrial and submucoperiosteal dissection was performed on the patient. An external incision was made in the septal mucosa. Using a cotton ball, the submucosal fascial graft was inserted into the area marked in the previous image, and secured externally with PDS sutures. It was ensured that most of the fascial graft remained submucosal. This graft area is shown with purple dashed arrows.
Image 4: The inserted septal graft is shown with red arrows. The patient describes a reduction in symptoms, particularly due to the small turbinate tail portion, which reduces air passage constriction in this area.
Challenges of Septal Implantation
As I have presented in this case, I would like to highlight the following challenges associated with intraseptal implantation in patients for whom it is planned, for various reasons:
- Risk of septal perforation: Careful evaluation of the nasal septum is necessary before the procedure. Generally, when light is shone from the opposite nasal cavity, if thin, light-transmitting areas are seen in the nasal septum, I warn the patient that "touching these areas may cause septal perforation." Similarly, when touched with the aid of an elevator, I explain that the nasal septum consists only of mucosa, and that the central septum was resected during septoplasty, and therefore implantation cannot be performed in this area.
The nasal septum normally consists of mucosa on both sides and a cartilage or bone septum in the middle. During septoplasty, cartilage or bone fragments in areas that obstruct or block the airway are removed. In this case, only the bilateral mucosa heals and closes over each other. Because it transforms into a very thin membrane-like area, incisions or dissections in this area can easily lead to perforation.
- Fixing the graft in the correct position within the nasal septum is not easy. If submucopeichondrial dissection is performed over a large area, the graft may shift within that area. To prevent this, the graft can be fixed to the septal cartilage or mucosa using dissolvable sutures.
- As I have shared with you here, sometimes the use of an endoscopic system is appropriate for placing the graft in the bony septum area, in the posterior septum section. Since full-thickness septal suturing is not possible due to the bony septum, sometimes it may be necessary to place the graft after external mucosal incision and then fix the graft with sutures.
3D nasal anatomy reconstruction is not always possible for our patients with empty nose syndrome. Reversing the altered nasal anatomy and returning it to its original state is not always possible, and nasal septum implantation is not possible in every patient. I will share a similar procedure, nasal septum shifting or septum repositioning, in other links.
To read other articles about empty nose syndrome prepared by Dr. Murat Enoz and published on this website, you can click on the search result link (you can access other articles by clicking on "more posts" at the bottom of the opened link) >> https://www.ent-istanbul.com/search?q=empty+nose
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
Appointment Phone: +90 212 561 00 52
Fax: +90 212 542 74 47
Comments
Post a Comment