Causes And Impacts In Revision Functional Reconstructive Nasal Surgery

OBJECTIVE : To analyze the causes and clinical effects of revision function reconstructive nasal surgery due to the failure of functional endoscopic sinus surgery(FESS)and / or nasal septum correction surgery.METHODS:We did retrospective study with 40 patients totally in our hospital from January 2013 to June 2017.Patient who underwent revision functional reconstructive nasal surgery(FRNS)after the failure of functional endoscopic sinus surgery(FESS)and nasal septum correction surgery.Nasal endoscopy and sinus CT examination were used to evaluate the abnormal nasal structure of patients.Abnormal nasal structure included the residual frontal recess area,stenosis of maxillary sinus orifice,unopened natural orifice of maxillary sinus,incomplete excision of anterior ethmoid and/or posterior ethmoidectomy,unopened sphenoid sinus orifice,residual deformity of middle turbinate,outward migration of middle turbinate,incomplete uncinectomy,deviation of nasal septum,especially dislocation of anterior end of nasal septum,residual nasal deviation,nasal column malformation and nasal lobule malformation.The subjective symptoms were evaluated by visual analogue scale(VAS),and the characteristics of objective examination were evaluated by the Lund-Kennedy(L-K)score,and the Lund-Mackay(L-M)score.Preoperative evaluation of patients undergoing revision FRNS combined with the above three methods.The procedure was performed using the concept of nasal function reconstruction,dealing with all abnormal nasal structures found.All patients were followed up for 6 months or more.Lund-Kennedy score and VAS score were used to evaluate the postoperative condition,and the Lund-Kennedy score and VAS score were compared before and after the operation to observe the improvement of the patient’s condition before and after the operation.The therapeutic effects of revision FRNS were divided into three types: complete control,partial control and uncontrol.The complete control and partial control of the disease were recorded as effective,but the non-control was invalid.RESULTS: 1.40 patients with the failure of FESS and septal deviation correction were found the abnormal nasal structures as follows:(1)Abnormal sinus structure : the residual frontal recess area 38 cases(95%);stenosis of maxillary sinus orifice 35 cases(87.5%);incomplete anterior ethmoidectomy 34 cases(85%),including openning failure of ethmoidal bulla 15 cases(37.5%)and the unexposed ethmoidal apex 19 cases(47.5%);incomplete posterior ethmoidectomy 31 cases(77.5%);unopened sphenoid sinus orifice 26 cases(65%);unopened natural orifice of maxillary sinus 2 cases(5%);(2)Abnormal nasal structure:incomplete uncinectomy34 cases(85%);middle turbinate malformation 28 cases(70%);the residual deviation of nasal septum 36 cases(90%),including the residual deviation of nasal septal cartilage 20 cases(50%),the residual deviation of ethmoid bone vertical plate 18 cases(45%),the residual deviation of plough bone 14 cases(35%),the residual deviation of nasal spine 10 cases(25%),outward migration of middle turbinate 6 sides(15%),caudal septal deviation 3 cases(7.5%);(3)Abnormal external nasal structure :4 cases(10%)with residual nasal deviation.2 cases(5%)of both nasal column malformation and nasal lobule malformation.2.The total scores of Lund-Mackay scores in 40 patients one week before operation were all greater than 1.3.VAS score before and after revision FRNS:The VAS scores at one week before operation were as follows:stuff-y nose(6.31±2.61),snot(4.31±3.26),headache(3.53±3.36),hyposmia(3.92±3.73),fatigue(2.87±2.68),VAS total mean score(4.19±2.25).The VAS scores for 6 months and more after operation were as follows:stuff-y nose(0.03±0.16),snot(0.00±0.00),headache(0.00±0.00),hyposmi(3.92±3.73),fatigue(0.00±0.00),VAS total mean score(0.12±0.30).The postoperative scores of stuff-y nose,snot,headache,hyposmia,fatigue,VAS total mean score were lower than preoperative scores,and there was significant difference between preoperation and postoperation(P<0.05).4.Lund-kennedy score before and after revision FRNS:The postoperative Lund-Kennedy score(0.23 ±0.83)was significantly lower than that before operation(7.40 ±5.00).The difference was statistically significant(P < 0.05).5.Follow-up for 6 months or more showed that 39 cases were completely controlled,1 case was partially controlled,0 case was not controlled,and the total effective rate was 100%.CONCLUSION: 1.The main causes of failure of FESS include: the residual frontal recess area,incomplete maxillary sinus orifice,incomplete anterior ethmoidectomy and / or posterior ethmoidectomy,unopened sphenoid sinus orifice,incomplete uncinectomy,residual deformity of middle turbinate,residual deformity of middle turbinate and outward migration of middle turbinate.2.The main reasons for the failure in the correction of nasal septum deviation included: the vertical plate of ethmoid bone was not well treated,the nasal spine of palatal bone was not treated,the deviation of ploughbone was not treated,the deviation of nasal septum cartilage was not corrected,and the dislocation of the caudal end of nasal septum was not treated.3.The lack of basic technical training of FESS is one of the residual frontal recess area and restenosis after the opening of each sinus ostium.4.With the concept of nasal function reconstruction,both nasal septum reconstruction surgery,askew nose correction surgery,columnar malformation and nasal lobule malformation and nasal cavity and sinus diseases were treated in the same period,and the nasal sinus ventilation and drainage were satisfactory.