Authors: Vikas Sinha*, Viral A. Chhaya**, Dilavar A. Barot***, Parin Patel****, Swapna Patil****, Vishal Parmar, Prashanth C.D.****, Kapil****, Jay Dave****, Nikhil Gupta****
*Dean, Professor E.N.T., **Professor and Head, ***Assistant Professor, ****Resident
Institution: Department of Otolaryngology and Head and Neck Surgery, M. P. Shah Medical College, Jamnagar (Gujarat), India
Dr. Vikas Sinha
Dean, Prof E.N.T.
M.P.Shah Medical College
Jamnagar (Gujarat), India
The authors present the surgical technique of a modified Young's procedure for the treatment of atrophic rhinitis. Surgical steps are illustrated with both pictures and a step by step video. The procedure consist of partial staged closure of the nasal airway using intranasal skin and mucosal flaps.
Thirteen patients underwent the procedure. Nine patients had healing of the flaps and complete relief of symptoms, Three had breakdown of the flaps but still developed postoperative airway restriction and improvement in their symptoms.
Atrophic rhinitis is a chronic nasal disease characterized by progressive atrophy of the mucosa and underlying bone of the turbinates. There are viscous secretions which rapidly dry and form a crust which emits a characteristic foul odor called ozaena or stench (like the bad smell of a cadaver) from the patient's nose. The patient remains unaware of his condition because of anosmia. The main problem with this disease is social boycotting due to the bad smell. Sometimes even maggots reside inside the nose which can lead to meningitis. Maggots are the larval form of the fly particularly of the genus Chrysomia (most common fly responsible for nasal Myiasis in India), C Megacephala, or C.Phaonis 1
The exact etiology of atrophic rhinitis is unknown. But Coccobacillus, Bacillus mucosus, Coccobacillus foetidus ozaena, Diphtheroid bacillus and Klebsiella ozaena are the causative organism.2 Primary atrophic rhinitis is a condition which has no specific etiology. Possible causes are infections, hormonal dysfunction, dietary deficiencies, vascular disease, nutritional disorders, autonomic dysfunction and autoimmune diseases. Atrophic rhinitis is most commonly seen in lower socioeconomic status families, especially in females, and in poorly nourished persons. Deficiencies in Vitamin A and D, iron and proteins can be contributory factors. In present day India, this disease is not so common due to improvement in the socioeconomic status of the population. Patients most frequently complain of nasal obstruction due to crusting, associated headaches and anosmia.
The initial medical treatment are nasal drops consists of 25% glucose with glycerin. The drops inhibit the proteolytic organisms. The main medical treatment is symptomatic and not curative. It consists of good nasal hygiene and cleaning the nose by means of alkaline nasal douching. The alkaline nasal solution consists of 30 gm of sodium bicarbonate, 30 gm of sodium biborate and 60 gm of sodium chloride.3 The patient should take one teaspoon of this mixture and dissolve it in a glass of lukewarm water. The patient should do the nasal douching at least 2-3 times daily.
The surgical treatment is aimed mainly to reduce the nasal cavity by means of putting acrylic nasal implants in the floor and lateral wall, injection of Teflon paste, insertion of cartilage, fat or bone pieces in the floor and lateral wall. Young4 described the method to raise flaps or folds of skin inside the nostril and suture the flaps together in order to have complete interruption of airflow. The naris are opened after several months.
This is the case study of 13 patients with atrophic rhinitis who had undergone a modified Young’s Operation. The surgeon for all cases was the first author. The male to female ratio was 4:9. All the patients were between 18-36 yrs of age. All the patients were desperate for any treatment including surgery since they were socially boycotted due to a bad smell. In one patient the smell was interfering with his sexual life since his partner disliked the smell. All patients were instructed to meticulously use alkaline nasal douching to reduce the crusts in their nasal cavity. All the cases had a thorough inspection of their nares to ensure they were free of maggots. All patients were tested for syphilis and leprosy to to exclude other causes of atrophic rhinitis.
Operative steps: Although both the nasal cavities are normally wide and roomy (Fig 1), the modified Young’s Operation was planned in that nasal cavity where the patient develops symptoms of dryness, crusting and a foul odor. All the patients were operated upon under local anesthesia. Patients were pre-medicated with a combination of 1 ml. Fortwin (Pentazocin 50 mg.), 1 ml. of phenergan (Promethazine) and 1 ml. of atropine, that was given by injection approximately 40 minutes prior to the surgery. 2% xylocaine with 1; 200,000 epinephrine was infiltrated in the vestibular area at the medial side of the nasal cavity along the nasal septum (Fig 2) and the lateral side of nasal cavity (Fig 3). The injection creates hydro edema of the nasal lining which will both reduce bleeding and aid in the surgical dissection. The round surgical incision (Fig 4) was placed slightly posterior to the mucocutaneous junction. The inner mucosal flaps require less mobilization than the outer skin flaps, which are also hard to visualize during surgery.
The outer skin flaps are created laterally (Fig 5) and medially (Fig 6) using a pair of fine curved scissors. All of the flaps are freely mobilized to prevent any tension once the sutures are placed. Tension on the sutures increases the risk of wound breakdown and it also medializes the lateral wall of the nose, thus, altering the shape of the outside of nose at the vestibular area. Such a deformity can be very cosmetically displeasing to the patient. The medial mucosal fold (Fig 7) and lateral mucosal fold (Fig 8) is created by fine curved scissors taking extreme care not to tear it as mucosa is extremely thin in such cases.
The anterior part of the septum becomes exposed while elevating the skin and mucosal flaps on the medial side. However, this does not cause any problems postoperatively except the fear in the mind of the surgeon during the surgery. Each of the mucosal and skin flaps are sutured separately together creating a double-layered closure. Catgut is used as the suture, which is placed with great care so as not to tear the mucosal and skin flaps. Both flaps are atrophied and the sutures can easily tear through the tissue, if undue tension is placed on the suture line. Figure 9 shows the closure of the inner mucosal flaps suturing the medial flap to the lateral flap. A 3 mm hole is left by placing a two cm. long thin polythene tube (Fig 10) in the naris. This prevents the wound and naris from closing completely. The medial and lateral skin flaps are sutured together (Fig 11) and the polythene tube is secured in the vestibule by means of sutures (Fig 12).
Afterwards, the surgical wound is sutured completely around the nasal tube (Fig 13). Betadine ointment is applied over the surgical wound (Fig 14) after the closure. if adequate mobilization of the flap has been accomplished, there will be no alteration in the shape of the vestibule (Fig 15) or lateral wall of the nose in the vestibular area.(Fig 16)
Followup: All the patients were advised to apply Betadine ointment for another one week. All the patients were given iron, vitamin B complex tablets and protein supplement to increase their nutrition. They were also given a short course of an antibiotic and an anti-inflammatory agent along with analgesic tablets. They were instructed to use a mosquito net strictly at night to prevent flies from laying eggs in the other side of the nose as patients are anosmic and there is less sensation in the nasal cavity. Such patients are an easy target for flies to lay eggs. Flies are attracted by the foul smelling nasal discharge emanating from the nose of an atrophic rhinitis patient. Only one male patient came for recanalization of the nose after one year. The remaining patients were happy with the reduced nasal airway.
Out of thirteen cases, nine cases had excellent healing. Three cases had breakdown of the sutures resulting in failure to achieve complete closure of the nose. The nine successful cases were very happy with reduced symptoms from one nasal cavity and out of the nine successful cases five cases returned for closure of the other nostril. The three cases which had breakdown of stitches were still quite happy as a residual fold was present in the lateral vestibular area that allowed less air entry and their symptoms were significantly relieved. Such cases are similar to the technique of vestibuloplasty as advocated by Ghosh P.5
Young3 , in 1967, was the first to describe closure of one or both nostrils by plastic surgery. After several months, or up to years after the procedure, the nostrils were reopened revealing absence of crusts and normal mucosa. However, Sinha, Sardana and Rajvanshi6 in 1977 found that bilateral closure was not tolerated by some patients who dislike mouthbreathing and the resultant nasal voice. However, partial closure of the nostril, with leaving a 3 mm. hole, is well tolerated and gives similar results with no recurrence of disease over a two year period. Any further increase in size of the hole rapidly decreases the success rate2.
We ensured the patency of the 3 mm. hole by placing a thin polythene tube stent (Fig 10) and securing it with stitches at the vestibule (Fig 12). The tube is removed after a week, helping to ensure the patency of the hole. We did not carry out the bilateral modified Young’s Operation simultaneously in both the nostrils but rather gave spacing of a 4-6 month period to the patient so that patient tolerates well the closure of one nostril. If both the nasal cavities are closed, the patients will have to adapt to mouthbreathing immediately and there is a change in their voice, developing a nasal tone. If the patient's occupation is lifting of heavy objects, it becomes difficult to fix the diaphragm without nasal breathing. It is also difficult for the patient for prolonged lip kissing with both the nostrils closed. However, all the patients who were married admitted to having no kissing in their life due to the bad smell. They also had reduced sexual relations with their partner due to the bad odor. Over the period of time, all successful cases returned to normal sexual life after the successful bilateral closure. Social boycotting of the patients also ceased..
The author presents a staged modified Young's Technique for the treatment of atrophic rhinitis in thirteen patients. Nine of the thirteen patients had significant reduction of their symptoms with resolution of the foul nasal smell and returned to full social functioning. The other three patients had improvement in their symptoms but revision surgery may be needed in the future.
1. Sinha V, Shah S, Ninama M, Gupta D, Prajapati B, More Y, Bhat V, Kedia BK. Nasal Myiasis J.Rhinol : 2006 Nov;13(2):120-123. View Abstract
2. Weir N. Acute and chronic inflammations of the nasal cavities. Ballantyne J and Groves J (eds). Scott Brown’s Disease of the Ear, Nose and Throat, Vol 3: The Nose and Sinuses. 4th edition. 1979; 176-179. View Book Information
3. Sinha V. Practical E.N.T. 2nd edition 2009, 45. View Book Information
4. Young A. Closure of the nostril in atrophic rhinitis. J Laryngol Otol. 1967; 80:524.
5. Ghosh P. Vestibuloplasty (a new one-stage operation for atrophic rhinitis). J Laryngol Otol. 1987 Sep;101(9):905-9. View Abstract
6. Sinha SM,Sardana DS, Rajvanshi VS. A nine year review of 273 cases of atrophic rhinitis and its management The Journal of Laryngology & Otology. 1977; 91(7):591-600. View Abstract