Nasal Aerodynamics and Rhinosinusitises |Nasan Aerodynamics | Septoplasty under control of nasal aerodynamics

PROTECTION OF THE INFERIOR NASAL PASSAGE FROM INSPIRATION

INSIDIOUSNESS OF THE UNILATERAL "SOUTHERN" NASAL AERODYNAMICS

SNORING WHEN NASAL RESPIRATION IS SAVED

Individual defence against infection by Severe Acute Respiratory Syndrome - SARS

1               2

Fig. 1 Distortion of the nasal septum because of the spine at the right:
1 - inferior turbinate bone (horizontal); 2 - nasal septum. 4-The shipp/crest of nasal septum
Fig. 2 Construction of a new air-directing "steering gear" at the left, with the "northern" type of the nasal aerodynamics at the right:
4 - The shipp/crest of nasal septum 5 -Construction of the "northern" type of the nasal aerodynamics also at the left




On Contraindication to Septoplasty
( Uliyanov Y.P. On Contraindication to Septoplasty. /Abstract / Otolaryngology-Head and Neck Surgery -August 1998: V.119, N 2, 153-154.)

ABSTRACT:

Modern septoplasty really leads to improvement in the nasal breathing, recovery of which serves as a criterion of the efficiency of surgery. However, due to the development of our knowledge of the nasal aerodynamics with detection of the "northern" and the "southern" types each of which provides for the nasal breathing to its full extent, but possesses differing protective possibilities, criteria of the efficiency of septoplasty and indications to the same demand a reconsideration.
Methods:
An examination was carried out of one hundred and fifty patients with distorted nasal septum who have been offered septoplasty due to complaints of disturbed nasal breathing. The age range was from 16 to 37. There were 97 males. After congestion of the nasal mucosa was stopped, in all patients the nasal aerodynamics was assessed. This has permitted determination of three main differences with traditional indications to septoplasty shown in the following three cases.
Results:
The examination of the nasal aerodynamics has detected:
Case 1. When the nasal breathing was disturbed at the right, there was a distortion of the nasal septum to the right with a "physiological bridge" being formed near the nasal valve typical for the "northern" type of the nasal aerodynamics. Disturbed breathing at the right is caused by inflammatory congestion.
Case 2. When the nasal breathing was disturbed at the right, a spine of the nasal septum at the right has been found which reached the inferior turbinate bone to form a kind of the air-directing "steering gear" at the nasal valve dividing the inferior and medial nasal passages according to the type of the "northern" variant of the nasal aerodynamics. Disturbed nasal breathing is caused by inflammatory congestion.
Case 3. A distortion of the nasal septum to the right forms the "physiological bridge", whereas hypertrophy of the inferior turbinate bone to the left, reaching the nasal septum, also forms the "physiological bridge" according to the type of the "northern" variant of the nasal aerodynamics. Disturbed nasal breathing is caused by vasomotor congestion.
        Conclusion:
1. If A distortion of the nasal septum forms the "northern" variant of the nasal aerodynamics, septoplasty must not be carried out in order not to destroy the already formed protective mechanism of the nasal aerodynamics.
2. With the increased spine of the nasal septum to reach the inferior turbinate bone at the nasal valve, the air-directing "steering gear" is formed (cicatricial bridges and unions in this area also form the air-directing "steering gear") typical for the "northern" type of the nasal aerodynamics. It is impermissible to remove this spine (scars, unions) to avoid destruction of the protective mechanism of the nasal aerodynamics.
3. When the nasal septum is deformed in such a way that the "northern" type of the nasal aerodynamics appears at one side with the "southern" one being formed at the opposite side, to recover the protective function of the nose at the opposite side, surgical construction of a new air-directing "steering gear" is indicated to unite the anterior edge of the inferior turbinate bone with the nasal septum and to separate the inferior and medial nasal passages in order to from thereby the "northern" type of the nasal aerodynamics also at this side.
4. When there is a compensatory distortion of the nasal septum, when the nasal breathing, after stopping nasal mucosal congestion at both sides, restores and corresponds to the "northern" type, septoplasty must not be performed to avoid destruction of the existing protective mechanism of the nasal aerodynamics.

INTRODUCTION
Since the papers of Fugall were published in 1882, septoplasty, a method of surgical correction of deformed nasal septum, has kept the leading place in endosurgery of the nose for over one hundred years, as this method influences the function of two halves of the nose at the same time. On the other hand, the smallest inaccuracies and mistakes in performing septoplasty may exert a negative impact on the nasal function. Therefore, rhinologists are constantly searching for the most efficient and safe methods of septoplasty. During recent decades great achievements have been achieved thanks to introduction of both new techniques and modern equipment. However, even now the variety of anatomical variants of deformed nasal septum hinders adoption of a standard method of their correction, whereas at present classical methods of septoplasty retain their value only as manuals (F.J.Stucker, 1982,1997). In every concrete case, a rhinologist has to choose a particular variant of intervention. Our knowledge of the nasal function and accessory nasal sinuses is continually deepened and widened along with corresponding changes in the tasks to be solved by septoplasty and the criteria of its efficiency. By now, new findings in nasal aerodynamics have revealed two functionally opposed types: the northern type with the expressed protective mechanism to resist the harsh air, which is adapted for any adverse climatic zones, and the southern type with underdeveloped protective mechanisms and suitable therefore only for the "soft" air of the southern latitudes. (Y.P.Ulyanov, 1996-1997). Consequently, the problem of septoplasty demands a further correction in order not to form, e.g., the "southern" type of the nasal aerodynamics in cases when nature has already created the "northern" type, and, whenever possible, to form a new protective mechanism similar to the "northern" type of nasal aerodynamics in those patients in whom nature has not been successful in creating the same. A key to solution of these problems lies in the surgical method of formation of transforming the aerodynamics of the southern type into its northern counterpart (Y.P.Ulyanov, 1997), which consist in construction of the air-directing "steering gear" near the nasal valve, where the physiologic bridge should be situated (but where it is absent) between the anterior edge of the inferior turbinate bone and nasal septum. Paradoxical as it may appear, it is at this very place that for over one hundred years surgeons have been dissecting the synechiae in the nose between the inferior turbinate bone and nasal septum in patients with disturbed nasal breathing, making use even of laser technology. The experience has shown this dissection to be inefficient, as the synechiae obstinately regenerate here due to quite understandable natural laws of survival (or natural selection), as it is the appearance in this place of the physiologic bridge that exerts a positive influence on formation of the reliable protective mechanism of the respiratory ways providing for viability of man in various climatic zones. In performing septoplasty, it is necessary to take into account these features of the nasal aerodynamics, the more so, as in the absence of some experience it is both not so simple to detect this physiologic bridge near the nasal valve and very important to retain this. We have described twelve main variants of formation of the physiologic bridge near the nasal valve (Y.P.Ulaynov, 1997) and shown that a role in the formation of this physiologic bridge is played not only by the noticeable inferior turbinate bone, but also by the spines and curvatures of the nasal septum.
METHOD
To discover this type of cases, we have carried out an examination of one hundred and fifty patients with distorted nasal septum who have been offered septoplasty due to complaints of disturbed nasal breathing. The age range was from 16 to 37. There were 97 males. After congestion of the nasal mucosa was stopped, in all patients the nasal aerodynamics was assessed. This has permitted determination of three main differences with traditional indications to septoplasty shown in the following three cases.
RESULTS:
Case 1. The patient complains of frequent rhinitis and stuffiness of the nose more to the right. An examination reveals a distortion of the nasal septum to the right with disturbed nasal breathing. The nasal mucosa is congested and inflamed, with the breathing being disturbed breathing at the right, so that the patient breathes only through the left half of the nose, which is these cases is subatrophic, dry and irritated because of the overload. The traditional approach is to shift the nasal septum to the left to open the access of air to the right half of the nose and to diminish the overload from its left half. However, a study of the nasal aerodynamics in these patients reveals that after mucosal congestion of the right half of the nose is eliminated, breathing through this half recovers almost completely, with the "physiological bridge" between the inferior turbinate bone and nasal septum being exposed (Fig. 1), which causes the air stream to enter through the medial nasal passage at inspiration and to leave the nose through the inferior nasal passage at expiration, providing therewith the maximum possible protective function of the nose. Taking this fact in consideration, if the nasal septum is shifted to the left, the already existing "physiological bridge" will be destroyed, so that the air stream will enter through the inferior nasal passage at inspiration, which would correspond to the "southern" type of nasal aerodynamics with a damage to the protective function of the nose. Therefore, in this case septoplasty should not be carried out because of the particular features of the nasal aerodynamics at the right. On the other hand, as this patient has the classical variant of the "southern" type of aerodynamics at the left, in which even after a shift of the nasal septum to the left until the medial line no "physiological bridge" will be constructed near the nasal valve, there are all indications for construction of a new air-directing "steering gear" at the left half of the nose according to our method (Fig.2) in order to create the "northern" type of the nasal aerodynamics. This method permits making a new air-directing "steering gear" at the nasal valve which guides the air stream at inspiration into the medial nasal passage recovering therewith the protective properties of the nose. Thereafter, subatrophy and dryness of the mucosa of the left half of the nose disappear, so that the mucosa becomes humid and soft without any signs of inflammation. In the right half of the nose, inflammation and mucosal congestion vanish, while the breathing recovers. An analysis of this example demonstrates that the original cause of inflammation in the nose was impaired nasal aerodynamics at the left with resulting stuffiness, in the first place, of the right half of the nose which was narrower that the left one. However, after traditional septoplasty in such cases the patient's state worsens more often than not, despite a recovery of the nasal breathing at the right. The patient begins to complain of dryness in the nasopharynx and throat and fits of suffocation similar to laryngospasms. After this surgery, patients catch cold more often, with development of pneumonia as a result of common cold, which is only natural in the "southern" nasal aerodynamics.
Case 2. The patients complains of frequent rhinitis and stuffiness of the nose more to the right. A front rhinoscopy reveals that the nasal septum is situated on the medial line, but there is a distinct spine of the nasal septum at the right which reached the anterior edge of the inferior turbinate bone (Fig.3). Disturbed nasal breathing at the right is caused by inflammatory congestion. In the left half of the nose, the mucosa is subatrophic and dry with signs of irritation, but without any congestion. The nasal breathing goes on largely through the left half of the nose. In this case, tradition dictates to remove this spine of the nasal septum at the right to alleviate the nasal breathing at this side and to eliminate the overload from te left half of the nose, as it is here that the inflammatory process starts. However, a study of the nasal aerodynamics in the right side reveals (Fig.3) that after mucosal inflammatory congestion of the nose is eliminated, breathing recovers completely, despite a union between the spine of the nasal septum and the inferior turbinate bone. The main air stream enters through the medial nasal passage at inspiration and goes out through the inferior nasal passage at expiration, according to the "northern" type of aerodynamics. It is quite obvious that in case this spine of the nasal septum is removed, the main air stream will enter through the inferior nasal passage at inspiration according to the "southern" type of aerodynamics, which will lead to a damage to the function of te nose. A study of the nasal aerodynamics at the left demonstrates the absence of the "physiological bridge" at the nasal valve, which is an evidence of the "southern" type of aerodynamics with the dry subatrophic mucosa which is very susceptible to frequent inflammations caused by common cold, as the air stream enters through the inferior nasal passage at inspiration with a damage to this passage. To let the main air stream shift at inspiration to the medial nasal passage, construction of the air-directing "steering gear" is indicated to this patient between the inferior turbinate bone and nasal septum according to the above-mentioned method (Fig.4).Thereafter, subatrophy and dryness of the mucosa of the left half of the nose disappear, so that the mucosa becomes humid and soft without any signs of inflammation. The right half of the nose is not impaired, either, so that patients recover. An analysis of this variant demonstrates that the original cause of inflammation in the nose was impaired nasal aerodynamics in the left half of the nose with resulting stuffiness, in the first place, of the right half of the nose which was narrower that the left one because of spine of the nasal septum. However, this spine does not interfere with breathing after mucosal inflammatory congestion of the nose is eliminated, playing an important role in normalization of the mucosa and protective function of the nose. However, in this case again, after traditional resection of the spine of the nasal septum in the right half of the nose the "southern" nasal aerodynamics is formed, which impairs the protective function of the nose through aggravating the overload of the mucosa of the inspiratory ways and providing for expansion of dryness and subatrophy to the mucosa of the pharynx, larynx and further on, increasing the risk of their involvement into the inflammatory process in common cold. Summing up the results of the analysis of these two cases, excluding the traditional septoplasty, the problem of normalization of the nasal aerodynamics at the opposite side should be also solved, where there is the "southern" nasal aerodynamics leading to development of the inflammatory process in the nose. Consequently, in these cases it is indicated to recover the protective function of the nose at the opposite side through surgical construction of the new air-directing "steering gear" connecting the anterior edge of the inferior turbinate bone and the nasal septum dividing the inferior and medial nasal passages according to the type of the "northern" variant of the nasal aerodynamics at this side, too.
Case 3. The patient complains of frequent rhinitis and stuffiness of the nose for a number of years. He controls these symptoms with vasoconstrictive nose drops. On inspection, congestion of the nasal mucosa is faintly expressed due to vasoconstrictive nose drops. However, the distortion of the nasal septum to the right is rather visible (Fig.5) almost reaching the anterior edge of the inferior turbinate bone. At the opposite side of the nose, the inferior turbinate bone is so much enlarged that it also almost reaches the nasal septum. It seems that the distortion of the nasal septum narrows the right half of the nose and impairs breathing, whereas the excessively enlarged inferior turbinate bone at the opposite side impairs breathing at the left. Therefore, to widen the right half of the nose, it is necessary to shift the nasal septum to the left with the help of septoplasty. However, this intervention will be interfered with the enlarged inferior turbinate bone of the left half of the nose which should be reduced with low conchotomy. A study of the nasal aerodynamics has shown that at the right the physiologic bridge is formed between the nasal septum and inferior turbinate bone, so that the main air stream at inspiration enters through the medial nasal passage, providing for adequate breathing of this half of the nose. At the same time, in the left half of the nose the enlarged inferior turbinate bone, almost reaching the nasal septum, also forms the "physiological bridge" and does not interfere with the main air stream coming through the medial nasal passage at inspiration, providing for adequate breathing of this half of the nose. As a result, despite the distorted nasal septum and the enlarged inferior turbinate bone, breathing through the nose is retained at both sides, corresponding to the "northern" type, so that no surgical correction is needed. This variant of distortion of the nasal septum is quite compensatory. As for the impaired nasal breathing, this is caused by vasomotor congestion of the nasal mucosa, which, after the action of vasoconstrictive drops stops, results in repeated stuffiness of the nose. Therefore, this patient needs specific treatment for vasomotor rhinitis. However, after traditional septoplasty, the "physiological bridge" is destroyed at the right, whereas after left-sided low conchotomy this destruction is also possible also at the left, which improves nasal breathing for a while, but does not cure vasomotor rhinitis, which, when cured, results in a considerable impairment of the protective properties of nasal aerodynamics, as new problems, typical for the "southern" type of the nasal aerodynamics, arise.
CONCLUSIONS:
1. If a distortion of the nasal septum forms the "physiological bridge" at the nasal valve (between the anterior edge of the inferior turbinate bone and the nasal septum), septoplasty must not be carried out in order not to destroy the already formed protective mechanism of the nasal aerodynamics.
2. With the large-size spine of the nasal septum reaching the inferior turbinate bone at the nasal valve and forming the air-directing "steering gear" (or presence of cicatricial bridges and unions in this area also forming the air-directing "steering gear") dividing the inferior and medial nasal passages, it is impermissible to remove this spine (scars, unions) to avoid destruction of the protective mechanism of the nasal aerodynamics.
3. When the nasal septum is deformed in such a way that the "northern" type of the nasal aerodynamics appears at one side with the "southern" one being formed at the opposite side, to recover the protective function of the nose at the opposite side, surgical construction of a new air-directing "steering gear" is indicated to unite the anterior edge of the inferior turbinate bone with the nasal septum and to separate the inferior and medial nasal passages in order to form thereby the "northern" type of the nasal aerodynamics also at this side.
4. When there is distortion of the nasal septum, when the nasal breathing is impaired due to nasal mucosal congestion but, after arresting this congestion, is restored at both sides and corresponds to the "northern" type, septoplasty must not be performed to avoid destruction of the existing protective mechanism of the nasal aerodynamics, whereas this kind of distortion of the nasal septum should be considered compensatory.
REFERENCES:
Stucker F.J. Management of the scoliotic nasal.J.Laryngoscope.1982;Vol.92, 2:128.
Stucker.F.J. Contemporary septal nasal surgery. J. Rossiyskaya Rinologya. 1997; 1:4-8. ( In Russian ).
Uliyanov Y.P. Nose aerodynamics. Arch. Otolaryngol. Head Neck Surg. 1995; 121: 352.
Uliyanov Y.P. Nose aerodynamics. Jor. Vrach.(Moscau),1996; 11: 39-40.
Uliyanov Y.P. Surgical reconstruction of nasal aerodynamics. XYI World Congr. Of Otolar. Head Neck Surg.(Sydney, Australia, 2-7 March, 1997: 1591-1595.
Uliyanov Y.P. Physiological bridge represented by the nasal valve and its variants. XYI World Congr. Of Otolar. Head Neck Surg.(Sydney, Australia, 2-7 March, 1997: 1597-1601.
Uliyanov Yu. Clinical Medicine (Reference book of a practicing physician). MSPI, Moscow, 1997,V-2:1103 - 1152. Fugall (1882) cite by F.J.Stucker (1977).
Legends for Illustrations:
1) The nasal septum.
2) Physiological bridge represented by the nasal valve.
3) The new air-directing steering gear.
4) The spine of the nasal septum
5) The traditional septoplasty,

Fig. 1: Distortion of the nasal septum forming the "northern" type of the nasal aerodynamics at the right.

Fig. 2: Construction of the "northern" type of the nasal aerodynamics also at the left, with the distortion of the nasal septum to the right.

Fig. 3: Distortion of the nasal septum because of the spine at the right.

Fig. 4: Construction of a new air-directing "steering gear" at the left, with the "northern" type of the nasal aerodynamics at the right.

Fig. 5: Distortion of the nasal septum in the compensatory variant.