Tailored nasal surgery for normalization of nasal resistance

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 submucosa 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.