Historically concurrent FESS/rhinoplasty was avoided due to concerns of increased risk of complication. Recent studies have shown that FESS/rhinoplasty can be performed simultaneously with good outcomes and no significant increase in complications. A thorough and effective approach to the patient with sinonasal obstruction requires attention to aesthetic, functional, and inflammatory issues. Medical treatment is an important adjuvant to surgery in order to optimize outcomes by improving patient symptoms long-term. Surgery for these patients should be performed in a careful, stepwise approach to address the nasal septum, inferior turbinates, paranasal sinuses, and external nasal structures.
Since its introduction in 1986 FESS has emerged as the standard surgical treatment of chronic sinusitis. Simultaneously, there has been an increased demand for facial plastic surgery, with many patients interested in improving facial aesthetics as well as their functional nasal issues. During this period, the importance of the nasal valve to functional nasal surgery outcomes has become more apparent. Effective reconstruction of the nasal valves, both internal and external, is critical to optimizing functional outcomes and quality of life. Many of these rhinoplasty candidates have inflammatory rhinitis and CRS that contributes to their nasal breathing difficulties. These issues can be overlooked and failure to address them can lead to inadequate treatment of the patient’s sinonasal complaints.
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The performance of concurrent functional endoscopic sinus surgery (FESS) and rhinoplasty is relatively safe and the complication rates are similar to those when the procedures are performed independently.
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Many patients with functional or aesthetic nasal issues who present with nasal obstruction may also have concurrent sinonasal inflammatory disease. A thorough evaluation is required to identify any inflammatory issues such as allergic rhinitis or chronic rhinosinusitis (CRS).
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A comprehensive plan for patients with nasal obstruction must include both surgical and medical treatments including FESS, rhinoplasty, and antiinflammatory medications.
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Surgery for these patients should be performed in a careful, stepwise approach to address the nasal septum, inferior turbinates, paranasal sinuses, and external nasal structures. Careful attention is given to the internal and external nasal valves during rhinoplasty.
Historically, surgeons were wary of combining sinus surgery and rhinoplasty because of concerns of significant disruption of internal and external nasal structures as well as spread of infection to adjacent surgical sites. However, with the advent of minimally invasive techniques for performing FESS there is minimal disruption to nasal structures that support the external nose, and with present perioperative antibiotic therapy, contamination of the external nose from sinusitis is low.
The pros and cons of concurrent FESS and rhinoplasty
When considering whether to perform a concurrent FESS and rhinoplasty, the surgeon must weigh the potential risks and benefits of this type of procedure. Fakhri and Citardi describe several potential considerations that argue against the simultaneous performance of these surgical procedures. Millman and Smith describe a case of glabellar abscess, septic shock, and myocarditis after a FESS and rhinoplasty. Fakhri and Citardi suggest that FESS on patients with CRS who are frequently infected may induce bacteremia and that performing osteotomies may allow for a periosteal breach of infection that could result in soft tissue infections. The use of allogenic or synthetic grafts may also increase risks of local infection. Postoperative bleeding and hemorrhage is an inherent risk to both rhinoplasty and FESS. Theoretically this risk may be additive when both procedures are performed at the same time. The potential sites of bleeding differ for each of these procedures and therefore the source of postoperative hemorrhage may be difficult to ascertain.
Rhinoplasty causes intranasal as well as soft tissue postoperative edema, resulting in nasal and periorbital swelling. This edema could conceivably mask a postoperative orbital complication caused by a concurrent FESS. In addition, this situation may make postoperative debridement, which is critical to successful endoscopic sinus surgery (ESS) to reduce crusting and scar formation, difficult. Postoperative debridement requires endoscopic manipulation of the nose and sinonasal passages in the immediate postoperative period. This exercise could cause movement or disruption of the grafts and osteotomies created during the rhinoplasty, leading to a worse aesthetic result. Friedman reported medial collapse of the ascending process of the maxilla after a combined FESS/rhinoplasty, causing collapse of the nasal valve and concavity of the nasal side wall.
Increased risk of soft tissue and nasal infection remains a primary concern when performing concurrent FESS and rhinoplasty. Table 1 outlines several recent studies that describe concurrent FESS/rhinoplasty. Many of the studies did not report intranasal or soft tissue infections, whereas those studies that did report this complication had a rate of 2% to 2.3%. This finding is consistent with the rates of postoperative rhinoplasty infections, typically reported at between 1.7% and 2.7%. Lee and colleagues reported a slightly higher postoperative infection rate, with 4 of their 55 (6%) patients developing cellulitis. Of their cases, 51% were patients who had gross sinonasal purulence evident at the time of surgery, indicating active or acute infection. This situation may have contributed to their higher reported incidence of cellulitis after FESS/rhinoplasty, although none of these patients had gross purulence at the time of surgery. Overall, the rate of postoperative infections in these studies is consistent with those published for FESS and rhinoplasty performed independently. This finding argues against the theory that performing the 2 procedures simultaneously increases the rates of postoperative sinusitis, vestibulitis, or cellulitis.
| Study (n) | Procedures | FESS Indication | Complications (n, %) |
|---|---|---|---|
| Sclafani and Schaefer (13) | FESS (n) Closed rhinoplasty (3) Open rhinoplasty (10) | CT evidence of persistent sinusitis after medical therapy | None reported |
| Costa et al (13) | Maxillary/mandibular osteotomies FESS Open rhinoplasty | Endoscopic or CT evidence of anatomic obstruction or inflammatory disease | None reported |
| Inanli et al (45) | FESS Open rhinoplasty | Endoscopic or CT evidence of anatomic obstruction or inflammatory disease a | Postoperative hemorrhage (3, 6.6) Synechiae (2, 4.4) Periorbital emphysema (1, 2.2) |
| Kirchner and Dutton (48) | FESS Closed rhinoplasty (27) Open rhinoplasty (21) | Endoscopic or CT evidence of persistent sinusitis after medical therapy | Facial pain (1, 2) Unilateral nasal obstruction (1, 2) Unilateral facial cellulitis (1, 2) |
| Marcus et al (44) | FESS Closed rhinoplasty (27) Open rhinoplasty (17) | Endoscopic or CT evidence of anatomic obstruction or inflammatory disease | Vestibulitis (1, 2.3) Cellulitis (1, 2.3) |
| Lee et al (55) | FESS Open rhinoplasty | Evidence of persistent sinusitis after medical therapy b | Postoperative epistaxis (2, 3.6) Cellulitis (4, 6) |
| Toffel (122) | FESS Closed rhinoplasty | Endoscopic or CT evidence of persistent sinusitis after medical therapy | Postoperative hemorrhage (3, 2.5) Synechiae (27, 22) Lamina papyracea defect (2, 1.6) |
a Excluded patients with frontal or sphenoid sinusitis.
b 51% of cases had acute purulent debris at time of surgery.
Three of the concurrent FESS/rhinoplasty studies in Table 1 reported postoperative epistaxis or hemorrhage, with a rate between 0% and 6.6% across all studies. Postoperative synechiae were also reported in these studies at rates between 4.4% and 22%. Minor complications such as epistaxis, synechiae, and periorbital ecchymosis or emphysema after FESS are reported at rates between 2% and 21%. Minor complications of rhinoplasty such as epistaxis have been reported at rates between 2% and 4%. These rates are comparable with those reported in the studies in Table 1 , which indicates that there is no additive risk of minor complications when performing concurrent FESS and rhinoplasty. The investigators of these studies advocate combining these procedures only in patients with less severe sinus disease arbitrarily assessed by Lund-Mackay scores less than 8.
Displacement of nasal structure and grafts caused by endoscopic manipulation as well as inability to perform necessary postoperative FESS debridements secondary to increased intranasal edema has also been discussed as potential contraindications to performing concurrent FESS/rhinoplasty. Although Friedman described a case of posterior prolapse of the ascending process of the maxilla after simultaneous FESS and rhinoplasty, none of the larger case series has reported this problem. Of the studies outlined in Table 1 , only Sclafeni and Schaefer clearly describe their postoperative debridement regimen. They performed endoscopic debridement at 5 to 7 days after surgery and had their patients start nasal rinses at that time. None of the studies report difficulty with performing sinus debridements or disruption of grafts or osteotomies as a result of endoscopic manipulation in the postoperative period. Sclafeni and Schaefer did find an increased duration of nasal tip and dorsum edema after concurrent FESS and rhinoplasty. These investigators found that the duration of postoperative nasal edema was highly correlated with the severity of sinusitis on patient preoperative computed tomography (CT) scan reflected by their Lund-Mackay scores. The investigators theorize that increased intranasal edema after FESS may cause a secondary impairment in external nasal lymphatic drainage as well as venous congestion.
The aforementioned studies have shown that concomitant FESS and rhinoplasty can be performed safely and effectively. There are several advantages of concurrent FESS and rhinoplasty, many of which stem from the efficiencies gained from performing each procedure simultaneously. The most obvious advantage is that the patient’s functional and aesthetic nasal issues can be addressed along with their sinuses in a single, minimally invasive outpatient procedure. Because the patient with CRS and functional nasal issues undergoes 1 definitive procedure, hospital time, surgical costs, and recovery time are reduced. Many patients who present with complex functional and inflammatory issues require a comprehensive evaluation and treatment plan. This goal is most effectively accomplished with a multidisciplinary approach and a medical and surgical treatment plan that efficiently addresses these issues. This approach is described in the following section.
Evaluation and surgical planning for the rhinoplasty patient with allergic rhinitis or chronic sinusitis
Although it has never been prospectively evaluated, many patients with functional or aesthetic nasal issues who present for consideration of rhinoplasty may also have concurrent sinonasal inflammatory disease. Both allergic rhinitis and CRS can cause symptoms of obstructed nasal breathing and congestion. Although both should be treated medically, patients with CRS may also benefit from FESS to improve their symptoms and quality of life. It is important for the physician to be able to distinguish these 2 entities and establish a diagnosis and effective treatment plan before rhinoplasty to optimize the patient’s outcome. The surgeon should be able to determine those patients who would benefit from concurrent FESS and rhinoplasty.
Evidence based clinical practice guidelines have been published to assist physicians with the diagnosis and treatment of sinusitis. Three cardinal symptoms have been identified for diagnosing sinusitis based on their high sensitivity and specificity for acute sinusitis. These are purulent nasal discharge, nasal obstruction, and facial pressure, pain, or fullness. Hyposmia is also sensitive for CRS. CRS is defined as the presence of two or more of these symptoms lasting for longer than 12 weeks. Symptom based criteria alone are non-specific and therefore objective findings of inflammation either on CT scan or endoscopy is required to make the diagnosis. Acute bacterial rhinosinusitis (ABRS) is treated medically and defined as the presence of the three cardinal symptoms and/or signs of inflammation for longer than 10 days or worsening within 10 days. Recurrent acute sinusitis is diagnosed when 4 or more episodes of ABRS occur per year, without signs or symptoms of sinusitis between episodes. Patients with recurrent acute bacterial sinusitis (ABRS) or CRS as defined by the clinical guidelines outlined by Rosenfeld and colleagues who have failed medical therapy are candidates for FESS. Those patients with suspected CRS or recurrent sinusitis who are candidates for rhinoplasty should be evaluated and treated before scheduling them for concurrent FESS/rhinoplasty. The patient’s past medical history should include a detailed evaluation of symptoms and their associated time course to ensure that they meet the aformentioned criteria for CRS or recurrent sinusitis. Sinus CT scans should be obtained and nasal endoscopy performed to document the presence of inflammation. For those patients with recurrent sinusitis, a CT scan and endoscopy can be performed to confirm the presence of inflammation during an episode. This strategy is helpful to make an accurate diagnosis and rule out imitators of sinusitis such as headache or migraine disorders, which can manifest with similar symptoms. Although CT scans are not advocated for the diagnosis of ABRS, they may be helpful as a preoperative assessment in patients with recurrent sinusitis to determine which sinuses should be addressed during FESS.
CT scans can also be helpful to identify structural anomalies that can contribute to functional nasal obstruction. Fig. 1 shows the CT scan of a patient with bilateral nasal obstruction. Her nasal examination showed only mild bilateral internal nasal valve collapse and a subtle septal deviation. However, her CT scan, obtained by the facial plastic surgeon, showed bilateral concha bullosa. Failure to address these issues would have led to inadequate surgical treatment of her nasal symptoms. Fig. 2 shows the CT scan of a patient who was evaluated with left nasal obstruction greater than right. His nasal examination showed a significant left deviated septum. In addition his CT scan revealed a hyperpneumatized right-sided anterior ethmoid cell that was medializing his right middle turbinate and pushing on the septum. This cell was reduced at the time of his septoplasty to allow for lateralization of the middle turbinate and medialization of his septum. These cases illustrate how CT scans can show anatomic sinonasal abnormalities that should be addressed at the time of septorhinoplasty to maximize surgical outcome.
Similar to allergic rhinitis and nonallergic rhinitis, patients with CRS should be treated with medical therapy before considering FESS or any surgical procedure. Although there is no consensus on what constitutes maximal medical therapy, generally a 2-week to 4-week treatment regimen with appropriate antibiotics and oral corticosteroids is recommended. For those patients whose symptoms and signs of inflammation persist despite medical therapy, FESS is an effective treatment.
Evaluation of nasal valve disease begins with questions regarding any preferred side of breathing, worsening of breathing under physical strain, improvement on pulling 1 side of the cheek (the instinctive Cottle maneuver), or worsening with certain positions while asleep. During physical examination the surgeon must carefully examine both the external and internal nasal valves. The external nasal valve is the area of the nasal vestibule under the nasal ala formed by the caudal septum, the alar rim, and the medial crura of the alar cartilages. This area represents the first component of nasal resistance. Any caudal septal deviation, concavity of the alar rim, or dynamic functional collapse should be noted. Furthermore, a modified Cottle maneuver is performed using an ear curette to support the lower lateral cartilage in order to determine if there is subjective improvement in nasal obstruction. Next, the internal nasal valve is examined. This area comprises the dorsal septum, the caudal border of the upper lateral cartilage, and the anterior aspect of the inferior turbinate. Any high septal deviation that can compress the internal nasal valve should be noted. The upper lateral cartilage should be examined for concavity or static collapse, and a modified Cottle maneuver supporting the upper lateral cartilage should be performed, with any subjective improvement in nasal airflow noted. Identification of the presence of internal or external nasal valve collapse helps the surgeon to determine if using batten grafts to address the internal or external nasal valves, or spreader grafts to address the internal nasal valve is of most benefit to the patient.
We advocate a multidisciplinary approach to the evaluation of patients with a history of aesthetic, functional, and inflammatory sinonasal problems. Because these patients often present to a subspecialized otolaryngologist, it is important for the evaluating surgeon to focus on all potential causes of the patient’s concerns, even if their treatment is outside the surgeon’s surgical expertise. Careful screening is conducted by our facial plastic surgeon (PB) and rhinologist/endoscopic sinus surgeon (DR) during the evaluation of a patient with sinonasal issues. Rhinoplasty candidates with symptoms suggestive of inflammatory sinonasal disease ( Box 1 ; Table 2 ) are referred to our endoscopic sinus surgeon for further evaluation, medical treatment, and consideration of FESS. Similarly, patients with sinusitis with functional breathing issues and external structural abnormalities such as internal nasal valve collapse or a twisted nasal dorsum are referred to our facial plastic surgeon. This type of collaboration leads to a comprehensive treatment plan with medical and surgical therapy to optimize outcome and patient satisfaction. These patients often require long-term follow-up and treatment by a rhinologist for their inflammatory sinus disease even after successful FESS. Fig. 3 outlines a multidisciplinary algorithm for the preoperative evaluation and treatment of patients presenting with aesthetic, functional, and inflammatory sinonasal complaints.
Allergic Rhinitis
Sneezing
Itchy eyes/eye rubbing
Itchy nose
Clear rhinorrhea
Seasonal symptoms
Family history of allergic rhinitis
Eczema or food allergy
Nonallergic Rhinitis
Persistent congestion/rhinorrhea without sneeze or itchy nose
Poor response to oral antihistamine
Symptoms exacerbated by:
Weather changes
Temperature changes/extremes
Perfumes/odors
Smoke/fumes
Older age at onset
Absence of allergens as a trigger
| Definition | |
|---|---|
| CRS |
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| Recurrent acute rhinosinusitis |
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