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The objectives of the surgical technique septorhinoplasty are to remodel and redesign the nose, to remove the excessive bone and cartilaginous structures, and/or to correct the nasal insufficiencies in order to obtain a harmonious proportion of the nose in regards to the other facial structures. Furthermore, septorhinoplasty is one of the most frequently used aesthetic-surgical otorhinolaryngological procedures. The cartilaginous part of the nasal septum is an integral part of the isthmus's region and has a significant role in the air's circulation and turbulence. Due to this central role of the nasal septum, it is of crucial importance to undertake an adequate surgical technique since it is the key for a successful treatment both in the functional, and the esthetic rhinosurgery. The deformities of the nasal septum might be localized in the bone or in the cartilaginous structures, but most often, they are present in both of the structures. The cartilaginous deviations are the ones which are most responsible for the obstruction of the nasal respiratory flow. For that reason, they have been adequately classified. In this in-depth study, the aims have been:
1. To objectify the nasal air resistance (nasal obstruction) using rhinomanometry while selecting patients for septorhinoplasty.
2. To evaluate the frequency and the intensity of the nasal symptoms in patients that are about to undergo septo/rhinoplasty, before and after the intervention.
3. To classify the deviations of the nasal septum in regards to the septal structural and anatomical changes based on the CT of the nose and the paranasal sinuses and on the intrasurgical findings.
4. To determine an adequate psychological personality model while selecting patients for septo/rhinoplasty.
Confirmed by clinically relevant data, the goal of this study has been to ensure its acceptance and implementation as a protocol for selecting patients for septo/rhinoplasty. The author points out that this is a prospective, as well as non-randomized study where a statistical analysis has been conducted on a total of 140 patients experiencing deviations of the nasal septum (deviatio septi nasi) separate from or along with the deformities of the nasal pyramid: rhinokyphosis, rhinoscoliosis, rhinolordosis ("saddle nose"), and "functional tension nose". The examined patients were added on the list for surgical septo/rhinoplasty procedures performed at the ENT Clinic at University Hospital in Skopje, during the period of September, 2008 till September, 2013. The rhinomanometry examinations were performed at the Institute of Occupational Medicine in Skopje, while the psychological tests were carried out with the assistance of a clinical psychologist and a psychiatrist at the Psychiatry Clinic at University Hospital in Skopje. The examined groups were divided according to the following parameters:
a) According to the degree of nasal obstruction, the patients were divided into 3 groups:
Group IA – patients with a severe degree of nasal obstruction (severe degree of nasal resistance).
Group IB – patients with a moderate degree of nasal obstruction (moderate degree of nasal resistance).
Group II – patients with a mild degree of nasal obstruction (mild degree of nasal resistance), clinically monitored for a year, and then agreed upon to undergo surgical intervention.
In all patients candidates for septo/rhinoplasty, nasal symptoms such as: nasal obstruction, rhinorrhea, nasal pain, headache, hyposmia, snoring, nasal voice, epistaxis and others were pre-surgically monitored. After the surgical intervention, a survey was conducted in order to find out how satisfied the patients were after the performed correction. The patients were offered with 5 scores, that is, 5 modalities: 1 – very satisfied, 2 – satisfied, 3 – undecided, 4 – dissatisfied and 5 – extremely dissatisfied.
b) According to the type of surgical technique applied while performing the surgical intervention, the patients were divided into two groups:
- group I – 1: in which septoplasty was performed; the group was constituted of patients with Dg. Deviatio septi nasi.
- group I – 2: in which septorhinoplasty was performed: the group was constituted of patients who besides nasal septum deviation, also had some deformity of the nasal pyramid, such as: rhinokyphosis, rhinoscoliosis, rhinolordosis ("saddle nose"), and "functional tension nose".
These two groups were then divided into two subgroups:
- subgroup I2-a: in which lateral and medial osteotomy was performed
- subgroup I2-b: in which osteotomy was not performed.
c) Psychological analysis was performed solely on patients candidates for septorhinoplasty who voluntarily accepted to fill in the questionnaire for selection of patients candidates for septorhinoplasty and assessment of their psychological predispositions. Based on a numerous world standardized tests and questionnaires that would be applicable to the patient candidate for intervention, a similar questionnaire, adapted to our region was devised, in which the following parameters were included: Selecting a patient for septo/rhinoplasty and assessing their psychological predispositions (Psychological testing – a questionnaire for self body image), Brief Symptom Inventory Test (BSI) with which an analysis was carried out on the acquired results of the questions posed to the patients candidates for septo/rhinoplasty. Through the Brief Symptom Inventory (BSI) test, which is a standard psychological test, the following psychological symptoms in patients were recognized: somatization, obsessive-compulsive reactions, interpersonal sensibility, depression, anxiety, phobic anxiety, and paranoid ideas. There have also been patients who have not displayed any of these symptoms. The methods used throughout the examination are rhinomanometry, as a method for objectifying the nasal air resistance and computed tomography of the nasal and paranasal sinuses. The examined nasal symptoms were then recorded and grouped in the scale of subjective nasal symptoms.
Intraoperatively, the structural deformities of the nasal septum were classified into six groups. The psychological tests for selecting patients for septorhinoplasty and assessing their psychological predispositions were carried out by means of specific questionnaires. Therefore, a surgical protocol was established, as well as surgical procedures and actions needed for septo/rhinoplasty. Throughout the examination, the PhD candidate had not strictly held close to one rigid course of action or another while performing esthetic or functional rhinosurgery. The surgical procedure performed at a particular case rather depended on the pathology of the septum. The statistical methods used for the analysis of the obtained results are also listed. Based on the results, the statistical processing, as well as through discussion, the following conclusions have been drawn:
1. Rhinomanometry is a method that objectively determines the degree of nasal obstruction. It is clinically a very important method because it provides a pre-surgical real objectification of the degree of nasal obstruction. In the study, the use of rhinomanometry was beneficial since it attained the clinical objective to distinguish and group the patients who were truly in need of septo/rhinoplasty and the patients that were supposed to be monitored and receive medicament treatments. Likewise, the study brought about evidence that there is indication for septoplasty in patients with mild degree of nasal resistance (mild deviation of the nasal septum which even though monitored for a year, without use of drugs/medicine or topical nasal steroids, was still present, therefore the need of septoplasty was unavoidable.In many patients that are in a need of both functional, and aestethetic-functional septorhinoplasty the open question is posed of whether there is a connection between the degree of nasal obstruction, the incidence and the intensity of the occurrence of nasal symptoms that are a result of the deviated nasal septum. Admittedly, it has been expected that most of these patients would suffer from asymmetrical nasal flow through the nostrils due to the deviation of the nasal septum and if the deviation of the nasal septum is more severe and the nasal resistance is greater, then the nasal symptoms are prominent which has led to one-sided or double sided hypertrophy of the nasal cavity.
2. The feeling of impaired breathing was described by the patients candidates for septo/rhinoplasty as a dominant symptom of nasal obstruction. The results from the research have demonstrated that pre-surgically, as well as during the check-ups in 3, 6 and 12 months, the patients who experienced mild nasal obstruction that had not posed a problem in their everyday life and sleep were the fewest. Listing headache as a predominant symptom in patients with nasal septal deviation and its constancy in the post-surgical period showed that the headache is also caused by certain subjective reasons most commonly of psychogenic nature, such as anxiety, restlessness and great expectations of the intervention. The rhinorrhea was drastically diminished as a result of the correction of the nasal septum that reduced the edema and the hypertrophy of the nasal mucosa, especially the changes in the nasal concha, which has led to the decrease of the exudation of the nasal secretion. The occurrence of epitaxis was detected along the nasal septal deviations in the front and front-back sections, but it was of no significance. Therefore, it was inferred that all other causes that might be of functional, inflammatory, subjective or other nature might bring about the occurrence of these symptoms. 3. The results showed the significant correlation between the anatomical (objective) and the psychological (subjective) causes that determined the frequency and the intensity of the occurrence of the nasal symptoms. An analysis was made on the classifications of the nasal septal deviations on Mladina, as well as on the classification based on the coronal transections of the nasal septum acquired by coronal and axial transections of the nasal septum obtained with computed tomography. Likewise, a comparison was made in regards to the correlation between the nasal deviation and the consequent changes in the middle nasal cavity by comparing the examinations with the ones performed by Baumann and associates in the study of classification of the nasal septal deviation. The systematic classification of the deviations of the nasal septum done in this study has a lot of advantages compared to the other previously mentioned classifications because the previously mentioned ones mostly encompassed the classifications in the region of the cartilaginous septum, without taking into account the role that the position of the nasal septum has in regards to the external configuration of the nose. The objective of this classification is to encompass all the pathological alterations of the nasal septum and to document them, in order to implement an adequate surgical technique. Other objectives of this classification are to make the systematic training of young rhino surgeons in septoplasty easier, as well as to make this occupation more interesting and more appealing.In the chapter on the Surgical Protocol during septo/rhinoplasty, the surgical procedures and actions while performing a surgical intervention of septo/rhinoplasty were determined and established.
4. Through several surgical techniques, one modern approach to performing the surgical technique septoplasty was demonstrated. The ultimate objective of this surgical procedure was to indicate that not only a medial location of the nasal septum, but also a medial location of the space between the septum and the nasal cavities was of vital importance for a proper nasal respiration. The motto as well as the benefit of an adequately performed intervention in septal surgery and surgery of the nasal concha is: "Not the septum, nor the nasal concha, but the space between them is the point".
5. By testing the psychological profile of a patient's personality, the idea was that the patient would come to a mature decision by being fully aware of the possible change that would take place and would change their life, not only physically, but spiritually as well. This would also be beneficial to the surgeon in making the right decision regarding the surgical course of the intervention; it would also be of great use in the post-surgical clarification of the objective expectations of the surgeon by the performed surgical procedure and the expectations of the patient.
Last but not least, a maxim that sums up the importance of experience.
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