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Vol. 84. Num. 3.May - June 2018Pages 263-400
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Vol. 84. Num. 3.May - June 2018Pages 263-400
Original Article
DOI: 10.1016/j.bjorl.2017.03.013
Evaluation of pre- and post-pyriform plasty nasal airflow
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Oscimar Benedito Sofia
Corresponding author
, Ney P. Castro Neto, Fernando S. Katsutani, Edson I. Mitre, José E. Dolci
Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
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Tables (8)
Table 1. Results of the NOSE Questionnaire in the pre- and postoperative of pyriform plasty.
Table 2. Pre- and postoperative results of nasal airflow measurements by rhinomanometry, with and without nasal vasoconstrictor, in the R and L nostrils, under 75Pa pressure.
Table 3. Pre- and postoperative results of nasal airflow measurements by rhinomanometry, with and without nasal vasoconstrictor, in the R and L nostrils, under 150Pa pressure.
Table 4. Pre- and postoperative results of nasal airflow measurements by rhinomanometry, with and without nasal vasoconstrictor, in the R and L nostrils, under 300Pa pressure.
Table 5. Results of the Wilcoxon test applied to the pre- and postoperative pyriform plasty, considering the NOSE questionnaire, improvement with statistical relevance.
Table 6. Results of the Wilcoxon test applied to the pre- and post-operative pyriform plasty, evaluated by rhinomanometry under 75Pa pressure.
Table 7. Results of the Wilcoxon test applied to the pre- and post-operative pyriform plasty, evaluated by rhinomanometry under 150Pa pressure.
Table 8. Results of the Wilcoxon test applied to the pre- and post-operative pyriform plasty, evaluated by rhinomanometry under 300Pa pressure.
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Abstract
Introduction

Nasal obstruction is a frequent complaint in otorhinolaryngology outpatient clinics, and nasal valve incompetence is the cause in most cases. Scientific publications describing surgical techniques on the upper and lower lateral cartilages to improve the nasal valve are also quite frequent. Relatively few authors currently describe surgical procedures in the piriform aperture for nasal valve augmentation. We describe the surgical technique called pyriform plasty and evaluate its effectiveness subjectively through the NOSE questionnaire and objectively through the rhinomanometry evaluation.

Objective

To compare pre- and post-pyriform plasty nasal airflow variations using rhinomanometry and the NOSE questionnaire.

Methods

Eight patients submitted to pyriform surgery were studied. These patients were screened in the otorhinolaryngology outpatient clinic among those who complained of nasal obstruction, and who had a positive response to Cottle maneuver. They answered the NOSE questionnaire and were submitted to preoperative rhinomanometry. After 90 days, they were reassessed through the NOSE questionnaire and the postoperative rhinomanometry. The results of these two parameters were compared pre- and postoperatively.

Results

Regarding the subjective measure, the NOSE questionnaire, seven patients reported improvement, of which two reported marked improvement, and one patient reported an unchanged obstructive condition. Regarding the rhinomanometry assessment, of 96 comparative measurements between the preoperative and postoperative periods, we obtained 68 measurements with an increase in nasal airflow in the postoperative period, 26 negative results, and two cases that remained unaltered between the preoperative and postoperative periods.

Conclusion

When analyzing the results obtained in this study, we can conclude that the piriform plasty surgical procedure resulted in nasal airflow improvement in most of the obtained measurements.

Keywords:
Nasal obstruction
Rhinomanometry
Acoustic rhinometry
Resumo
Introdução

A obstrução nasal é queixa frequente nos ambulatórios de otorrinolaringologia, e a incompetência da válvula nasal é responsável em grande parte dos casos. É bastante frequente também as publicações de trabalhos científicos descrevendo técnicas cirúrgicas sobre as cartilagens laterais superiores e inferiores para melhorar a válvula nasal. Relativamente poucos autores descrevem atualmente procedimentos cirúrgicos na abertura piriforme para incremento da válvula nasal. Descrevemos a técnica cirúrgica chamada piriformeplastia e avaliamos a sua eficácia de forma subjetiva através do questionário NOSE e de forma objetiva através do exame rinomanometria.

Objetivo

Comparar as variações do fluxo aéreo nasal pré e pós-piriformeplastia através da rinomanometria e do questionário NOSE.

Método

Foram estudados 8 pacientes que foram submetidos à piriformeplastia. Estes pacientes foram triados no ambulatório de otorrinolaringologia, pacientes estes que se queixavam de obstrução nasal, e que apresentavam resposta positiva a manobra de Cottle. Responderam ao questionário NOSE e foram submetidos a rinomanometria no pré-operatório. Após 90 dias foram reavaliados pelo questionário NOSE e pela rinomanometria pós-operatória. Os resultados desses dois parâmetros foram comparados pré e pós-operatoriamente.

Resultados

Em relação a medida subjetiva, questionário NOSE, sete pacientes referiram melhora, sendo que dois deles referiram melhora acentuada, e um paciente referiu quadro obstrutivo inalterado. Em relação ao exame rinomanometria, de 96 medidas comparativas entre o pré e o pós-operatório, obtivemos 68 medidas com incremento ao fluxo aéreo nasal no pós-operatório, 26 resultados negativos, e dois casos inalterados entre pré e pós-operatório.

Conclusão

O procedimento cirúrgico piriformeplastia conferiu melhora do fluxo aéreo nasal na maioria das medidas obtidas.

Palavras-chave:
Obstrução nasal
Rinomanometria
Rinometria acústica
Full Text
Introduction

Nasal obstruction is a common complaint in the general population. It is defined as a discomfort characterized by the feeling of insufficient airflow through the nose. The sensation of airflow obstruction through the nose can be one of the most severe symptoms of nasal disease. The degree of nasal obstruction causing symptoms is determined not only by the severity of the obstruction, but also by the subjective perception of nasal airflow obstruction.1

The nose, being the upper airway entrance along with its multiple functions, such as the airflow trajectory, a chemical sensor, and air conditioner, is the first line of defense against infections. In humans and mammals, the nose is divided into two distinct anatomical pathways, and each has its own blood supply and innervation. The nasal septum divides the nose into two cavities and these consist of a bony portion and a cartilaginous portion. The lateral wall of each of these cavities basically consists of three turbinates protruding into the nasal cavity.2

The nasal valve is comprised of four structures. Two components are anatomical: the angle formed between the upper lateral cartilage and the septum, and the lateral diameter of the pyriform aperture. Two components are mucovascular: the head of the inferior turbinate, which is an erectile tissue, as well as the mucous tissue of the caudal septum, located dorsally to the inferior turbinate. Narrowing of the pyriform aperture and congestion of the erectile tissue of the lateral wall, especially of the inferior turbinate, associated with septal deviations, determine resistance to nasal airflow.3

In a study that analyzed 88 noses of Korean individuals, mean values of 30.1mm were found for men and 28mm for women, transversally at the level of the pyriform aperture. The shape and size of the pyriform aperture exert a significant impact on the nasal breathing effectiveness. The size and shape of the nasal bones and the pyriform aperture can be used to clarify the anthropological characteristics of each race. The pyriform aperture of the Korean race is larger than that of the white race (Fig. 1).4

Figure 1.
(0.06MB).

(A) Measurement of the pyriform aperture at the junction of the nasal bones with the frontal maxillary process. (B) Greatest transverse diameter of the pyriform aperture.

The treatment of nasal obstruction attributed to nasal valve dysfunction is typically aimed at interventions addressed to the internal or external nasal valve component. A 2015 study indicates that these patients can attain respiratory function improvement through surgical correction at the level of the pyriform aperture. Of twenty-six patients undergoing pyriform plasty surgery, 23 (88%) reported a significant improvement in their nasal obstruction bilaterally. The other 3 (11.5%) had a less significant improvement. The result of this study was obtained subjectively through a self-administered questionnaire. In this study, measurements using CT scan showed values of 23.6–25.32mm in men and 22.6–23.7mm in women.5

Relief of nasal obstruction through partial removal of the maxillary nasal process may improve respiratory symptoms, dry mouth and throat, exclusive mouth breathing, posterior rhinorrhea, cough and irritation of the pharyngeal mucous membrane, voice alterations due to absence of nasal resonance, headache, pressure sensation in the eyes, and loss of taste.6

Because the severity of nasal obstruction symptoms is not well correlated with nasal obstruction measurements, it is important to record accurate measurements of the physiological nasal obstruction. Objective methods to obtain measures of nasal resistance and patency include rhinomanometry (RM) and acoustic rhinometry (AR). These two diagnostic methods provide important information of the nasal airway. In general, RM provides information on nasal airway flow and resistance, while AR shows anatomical section areas of the nasal cavity that may be decreased.7,8

The internal nasal valve (INV) is defined as the caudal portion of the upper lateral cartilage and also by the angle formed between the latter and the quadrangular cartilage. Laterally it consists of fibro-adipose tissue that joins the pyriform aperture, where accessory cartilage can be found. Medially, the INV is delimited by the nasal septum. Inferiorly, it is delimited by the premaxilla and posteriorly, by the head of inferior turbinate. The external nasal valve (ENV) is described as caudal structures to the INV, such as the nasal wing and ligaments juxtaposed to the lateral crus of the lower lateral cartilage (LLC), medially delimited by the columella, and inferiorly by the nostril floor.9

The surgical technique used to treat bone stenosis of the pyriform aperture was first described by Douglas6 in 1952. This pyriform aperture bone resection technique can be used in combination with rhinomanometry, which can be used to differentiate whether the nasal obstruction is essentially mucous by performing the test before and after the use of a nasal topical decongestant. The objective test is used in the quantitative evaluation of the benefit of drug and surgical therapies. The test can be used to evaluate the effectiveness of septoplasty and/or turbinoplasty in the treatment of nasal obstruction. In nasal physiology studies, rhinomanometry provides quantitative information on nasal mucosa response and changes of this mucosa in response to allergens and other types of chemical and physical stimuli.10

Nasal pressure is usually measured in Pascal (Pa). Pascal is the international standard unit and it is a very small unit. A pressure of 100Pa is equal to 1cm in height in the water column. Nasal airflow is usually measured in units of cubic centimeters per second (cm3/s).

Rhinomanometry is potentially the best method for objective measurement of nasal airflow obstruction, being very useful for the selection of patients who are candidates for septoplasty or nasal valve reconstruction.11

Methods

From April 2015 to April 2016, eight patients screened at the Otorhinolaryngology Outpatient Clinic were selected for the study. The study was submitted and approved by an Ethics Committee under Opinion number 796.464.

Patients of both genders, older than 16 years, presenting with nasal obstruction that improved with Cottle maneuver, were included in the study. All these patients were submitted to subjective evaluation by the NOSE questionnaire. Then, they were submitted to an objective evaluation of nasal airflow through rhinomanometry, using an Atmos Rhinomanometer 300® equipment, initially without the use of nasal vasoconstrictor and then using the vasoconstrictor Oxymetazoline 0.5mg/mL at a dose of 100μg, or two applications, followed by another application after 5min, totaling 150μg, according to the Committee report on standardization of rhinomanometry resolution.12

Patients with comorbidities that formally contraindicated any surgical procedure, patients with ulcero-granulomatous diseases and sinonasal tumors, those previously submitted to nasal surgery, and/or those with a caudal nasal septal deviation were excluded.

Surgical technique

  • 1.

    Patient placed under local anesthesia with 2% Lidocaine with Adrenaline 1: 200,000 and sedation with Propofol 200mg/20mL (2,6-diisopropylphenol) at a dose of 1.5–2.5mg/kg/dose.

  • 2.

    Antisepsis with chlorohexidine digluconate 2%.

  • 3.

    Marking of the incision in the upper gingival-labial groove bottom (Fig. 2).

    Figure 2.
    (0.06MB).

    Marking of the incision in the upper gingival-labial groove bottom.

  • 4.

    A 1.5cm incision at the bottom of the R and L upper gingival-labial groove in the nasal pyriform aperture, from the central incisor to the canine on each side, preserving the lip frenulum, using a surgical blade number 15.

  • 5.

    Divulsion by nasal planes and hemostasis using an electrocautery.

  • 6.

    Subperiosteal detachment at the level of the pyriform aperture, including the nasal floor (Fig. 3).

    Figure 3.
    (0.08MB).

    Subperiosteal detachment of the left pyriform aperture.

  • 7.

    Measurement and marking of the bone portion to be removed (Fig. 4).

    Figure 4.
    (0.1MB).

    Marking the bone portion to be removed.

  • 8.

    Bone removal using a 4-mm diameter steel drill, on the lateral wall of the pyriform aperture (4-mm erosion), under irrigation with 0.9% saline solution. The final result is exemplified in Fig. 5.

    Figure 5.
    (0.09MB).

    Left inferior-lateral portion of the pyriform aperture after removal with drill.

  • 9.

    Suture by nasal planes with Catgut 3.0.

  • 10.

    No nasal dressing or packing was used.

  • 11.

    The patients were re-evaluated 7 days after the surgery.

Three months after being submitted to surgery, the patients returned and answered the NOSE questionnaire, to the same examiner, and were submitted to postoperative rhinomanometry with the same equipment, with and without vasoconstrictor agent.

Results

The data collected through the NOSE questionnaire were analyzed quantitatively, and each patient score varied from 0 to 100, with zero score being attributed to the patient with a completely free nasal flow, without any obstruction, whereas the score 100 was attributed to the patient who had a completely obstructed nose. The results are shown in Table 1.

Table 1.

Results of the NOSE Questionnaire in the pre- and postoperative of pyriform plasty.

  Preoperative  Postoperative 
Case 1  85  70 
Case 2  70  55 
Case 3  55  55 
Case 4  80  15 
Case 5  90  25 
Case 6  85  60 
Case 7  75  35 
Case 8  75  45 

Result in number of points, ranging from zero to 100 points.

The Atmos Rhinomanometer 300® device provides nasal airflow results at the pressure levels of 75, 150 and 300 Pascal (Pa) using the device's own software. These values obtained through the measures of nasal flow and airflow resistance comprise a graph showing the curves for each case, obtained in the right and left nostrils.

The rhinomanometry results in pressures of 75Pa, 150Pa and 300Pa in each nostril before and after the use of nasal vasoconstrictor before and after the pyriform surgery are shown in Tables 2–4.

Table 2.

Pre- and postoperative results of nasal airflow measurements by rhinomanometry, with and without nasal vasoconstrictor, in the R and L nostrils, under 75Pa pressure.

    Without vasoconstrictorWith vasoconstrictor
    Pre-op flow (cm3/s)  Post-op flow (cm3/s)  Pre-op flow (cm3/s)  Post-op flow (cm3/s) 
Case 1R Nostril  324  372  384  512 
L Nostril  180  304  204  340 
Case 2R Nostril  212  280  332  380 
L Nostril  180  140  372  252 
Case 3R Nostril  184  252  276  236 
L Nostril  264  268  380  344 
Case 4R Nostril  228  128  280  248 
L Nostril  224  380  352  416 
Case 5R Nostril  204  336  292  336 
L Nostril  16  128  96  152 
Case 6R Nostril  212  220  396  456 
L Nostril  160  160  376  364 
Case 7R Nostril  148  184  424  524 
L Nostril  200  196  252  276 
Case 8R Nostril  196  124  180  324 
L Nostril  260  452  288  326 
Table 3.

Pre- and postoperative results of nasal airflow measurements by rhinomanometry, with and without nasal vasoconstrictor, in the R and L nostrils, under 150Pa pressure.

    Without vasoconstrictorWith vasoconstrictor
    Pre-op flow (cm3/s)  Post-op flow (cm3/s)  Pre-op flow (cm3/s)  Post-op flow (cm3/s) 
Case 1R Nostril  528  536  540  724 
L Nostril  244  428  416  480 
Case 2R Nostril  456  388  472  584 
L Nostril  240  208  556  420 
Case 3R Nostril  252  348  408  516 
L Nostril  408  388  556  1000 
Case 4R Nostril  316  280  416  376 
L Nostril  316  560  536  588 
Case 5R Nostril  224  424  440  484 
L Nostril  12  196  172  292 
Case 6R Nostril  312  324  556  720 
L Nostril  248  248  564  512 
Case 7R Nostril  220  264  620  1000 
L Nostril  280  256  364  556 
Case 8R Nostril  252  276  288  468 
L Nostril  380  348  384  460 
Table 4.

Pre- and postoperative results of nasal airflow measurements by rhinomanometry, with and without nasal vasoconstrictor, in the R and L nostrils, under 300Pa pressure.

    Without vasoconstrictorWith vasoconstrictor
    Pre-op flow (cm3/s)  Post-op flow (cm3/s)  Pre-op flow (cm3/s)  Post-op flow (cm3/s) 
Case 1R Nostril  696  716  736  1024 
L Nostril  328  600  636  664 
Case 2R Nostril  612  560  640  908 
L Nostril  308  264  704  624 
Case 3R Nostril  340  516  532  1000 
L Nostril  568  1000  768  1000 
Case 4R Nostril  488  420  556  520 
L Nostril  468  1000  1000  840 
Case 5R Nostril  372  808  600  684 
L Nostril  20  244  256  384 
Case 6R Nostril  468  488  716  1000 
L Nostril  340  384  1000  700 
Case 7R Nostril  316  464  832  1000 
L Nostril  404  388  500  556 
Case 8R Nostril  296  380  360  432 
L Nostril  508  872  560  688 

Statistical analysis was performed using the Wilcoxon method for the NOSE questionnaire results before and after the pyriform plasty, as well as for the nasal airflow results evaluated by rhinomanometry at pressures of 75Pa, 150Pa and 300Pa in the pre- and postoperative periods (Tables 5–8).

Table 5.

Results of the Wilcoxon test applied to the pre- and postoperative pyriform plasty, considering the NOSE questionnaire, improvement with statistical relevance.

Pair of variables  n  Mean  Standard deviation  Min.  Max.  Percentile 25  Percentile 50 (Median)  Percentile 75  Sig. (p
NOSE pre  76.88  11.00  55.00  90.00  71.25  77.50a  85.00  0.018b 
NOSE post  45.00  18.71  15.00  70.00  27.50  50.00a  58.75   

p, level of significance; Min., minimum; Max., maximum.

a

Results of the NOSE and pre- and postoperative rhinomanometry with nasal airflow increase in all cases at percentile 50 (median).

b

Statistically significant results.

Table 6.

Results of the Wilcoxon test applied to the pre- and post-operative pyriform plasty, evaluated by rhinomanometry under 75Pa pressure.

Pair of variables  n  Mean  Standard deviation  Min.  Max.  Percentile 25  Percentile 50 (Median)  Percentile 75  Sig. (p
[Pa75-wt/v] pre-op flow [r]  213.50  50.68  148.00  324.00  187.00  208.00a  224.00  0.483 
[Pa75-wt/v] post-op flow [r]  237.00  90.91  124.00  372.00  142.00  236.00a  322.00   
[Pa75-wv] pre-op flow [r]  320.50  79.96  180.00  424.00  277.00  312.00a  393.00  0.036b 
[Pa75-wv] post-op flow [r]  377.00  111.55  236.00  524.00  267.00  358.00a  498.00   
[Pa75-wt/v] pre-op flow [l]  185.50  78.24  16.00  264.00  165.00  190.00a  251.00  0.108 
[Pa75-wt/v] post-op flow [l]  253.50  118.83  128.00  452.00  145.00  232.00a  361.00   
[Pa75-wv] pre-op flow [l]  290.00  101.80  96.00  380.00  216.00  320.00a  375.00  0.327 
[Pa75-wv] post-op flow [l]  308.75  81.01  152.00  416.00  258.00  333.00a  359.00   

p, level of significance; wt/v, without vasoconstrictor; wv, with vasoconstrictor; r, right nostril; l, left nostril; P, Pascal; Min., minimum; Max., maximum.

a

Results of NOSE and pre- and postoperative rhinomanometry with nasal airflow increase in all cases at Percentile 50 (median).

b

Statistically significant results.

Table 7.

Results of the Wilcoxon test applied to the pre- and post-operative pyriform plasty, evaluated by rhinomanometry under 150Pa pressure.

Pair of variables  n  Mean  Standard deviation  Min.  Max.  Percentile 25  Percentile 50 (Median)  Percentile 75  Sig. (p
[Pa150-wt/v] pre-op flow [r]  320.00  113.58  220.00  528.00  231.00  282.00a  421.00  0.263 
[Pa150-wt/v] post-op flow [r]  355.00  92.40  264.00  536.00  277.00  336.00a  415.00   
[Pa150-wv] pre-op flow [r]  467.50  103.88  288.00  620.00  410.00  456.00a  552.00  0.017b 
[Pa150-wv] post-op flow [r]  609.00  199.10  376.00  1000.00  472.00  550.00a  723.00   
[Pa150-wt/v] pre-op flow [l]  266.00  120.63  12.00  408.00  241.00  264.00a  364.00  0.497 
[Pa150-wt/v] post-op flow [l]  329.00  126.05  196.00  560.00  218.00  302.00a  418.00   
[Pa150-wv] pre-op flow [l]  443.50  137.69  172.00  564.00  369.00  476.00a  556.00  0.141 
[Pa150-wv] post-op flow [l]  538.50  207.31  292.00  1000.00  430.00  496.00a  580.00   

p, level of significance; wt/v, without vasoconstrictor; wv, with vasoconstrictor; r, right nostril; l, left nostril; P, Pascal; Min., minimum; Max., maximum.

a

Results of NOSE and pre- and postoperative rhinomanometry with nasal airflow increase in all cases at Percentile 50 (median).

b

Statistically significant results.

Table 8.

Results of the Wilcoxon test applied to the pre- and post-operative pyriform plasty, evaluated by rhinomanometry under 300Pa pressure.

Pair of variables  n  Mean  Standard deviation  Min.  Max.  Percentile 25  Percentile 50 (Median)  Percentile 75  Sig. (p
[Pa300-wt/v] pre-op flow [r]  448.50  145.59  296.00  696.00  322.00  420.00a  581.00  0.123
[Pa300-wv] post-op flow [r]  544.00  147.42  380.00  808.00  431.00  502.00a  677.00 
[Pa300-wv] pre-op flow [r]  621.50  145.33  360.00  832.00  538.00  620.00a  731.00  0.017b
[Pa300-wv] post-op flow [r]  821.00  240.71  432.00  1024.00  561.00  954.00a  1000.00 
[Pa300-wt/v] pre-op flow [l]  368.00  168.18  20.00  568.00  313.00  372.00a  498.00  0.042b
[Pa300-wt/v] post-op flow [l]  594.00  321.81  244.00  1000.00  294.00  494.00a  968.00 
[Pa300-wv] pre-op flow [l]  678.00  251.17  256.00  1000.00  515.00  670.00a  942.00  0.889
[Pa300-wv] post-op flow [l]  682.00  183.15  384.00  1000.00  573.00  676.00a  805.00 

p, level of significance; wt/v, without vasoconstrictor; wv, with vasoconstrictor; r, right nostril; l, left nostril; P, Pascal; Min., minimum; Max., maximum.

a

Results of the NOSE and pre- and postoperative rhinomanometry with nasal airflow increase in all cases at percentile 50 (median).

b

Statistically significant results.

Discussion

The nose is physiologically very dynamic; volume alterations of its structures occur at all times and, therefore, we prefer to perform several tests on the same patient, so that we can reach a conclusion and a more accurate functional diagnosis.

Regarding the subjective analysis, performed through the questionnaire answered by our patients regarding quality of life (NOSE), in cases 1 and 2 the patients showed a slight improvement in their responses, and case 3 did not mention changes, maintaining the same index in the pre- and postoperative periods. As for cases 4, 5, 6, 7 and 8, the patients reported a marked improvement in nasal obstruction. The excellent results, with a marked improvement in nasal airflow, may be justified because these patients had nasal airflow obstruction that was more dependent on the nasal valve, mainly of the bone portion, that is, narrowing of the pyriform aperture.

The rhinomanometry is currently the most objective test for evaluation of nasal respiratory function. It should be used in accordance with the ISCR (International Standardization Committee on Nasal Airway Evaluation-1984).12 For this reason, we chose rhinomanometry as an objective method for the evaluation of our patients.

Using the rhinomanometry assessment, four comparisons were made at each pressure level, 75Pa, 150Pa and 300Pa, considering the right and left nostrils, before and after vasoconstrictor use, and before and after undergoing pyriform plasty. Therefore, we obtained a total of 12 measurement comparisons for each patient.

According to Cole3 in 2003, both the narrowing of the pyriform aperture and the congestion of the lateral wall erectile tissue, especially of the inferior turbinate, associated with septal deviations, determine nasal airflow resistance. This fact was observed in our results, where all patients showed nasal airflow improvement after the use of vasoconstrictors, before and after undergoing pyriform plasty.

According to Battacharyya and Deschler,2 the inferior turbinate is at a few millimeters from the pyriform aperture and, therefore, we believe that the increase in the diameter of the pyriform aperture promotes an area increase in this region of the inferior turbinate head, as well as in the region of the nasal wing, represented by the lower lateral cartilage.

Based on the reports of Bhattacharyya and Deschler,2 and Rohrich et al.,13 we can postulate that, due to the connection between the upper lateral cartilage and the pyriform aperture, after the pyriform plasty the ULC and the LLC should be positioned more laterally and increase the angle formed between the ULC and the nasal septum, that is, promote nasal airflow increase through the INV. As the ligament of Rohrich et al.13 is a fibrous connective structure that joins the lateral crus of the LLC to the pyriform aperture, it is expected that after the pyriform plasty, Rohrich's ligament be joined more laterally to the enlarged pyriform aperture, also promoting nasal airflow increase at the level of the ENV (Fig. 6).

Figure 6.
(0.14MB).

In red, the intersection of ULC and LLC with the pyriform aperture.

Spielmann et al.14 stated that each patient will have an indication of a specific technique, more appropriate for each case. We agree with this assertion and we believe that each case of nasal obstruction will require one or more associated surgical techniques to attain a good result, with pyriform plasty being one of them.

The Cottle maneuver can specify whether the nasal obstruction occurs at the level of the nasal valve area. This same maneuver was used in this study as one of the inclusion factors for the selection of patients who would be candidates for pyriform plasty (nasal obstruction with positive Cottle maneuver). Eventually, the best results of nasal airflow after pyriform plasty might be more pronounced if associated with other nasal surgical procedures, septoplasty and turbinectomy, for instance.14,15 We agree with these authors.

Associated surgical procedures and clinical treatments should be considered, as there was improvement in almost all cases after nasal vasoconstrictor use, demonstrating the presence of nasal mucosa edema.

Patients who have pyriform aperture atresia associated with ogival palate with bilateral crossbite, will benefit from surgically-assisted palatine disjunction. Those with maxillary atresia, without crossbite, have an indication for pyriform plasty. Both techniques promote the enlargement of the piriform aperture.16

If we analyze all rhinomanometry measures, both positive and negative, at an inspiratory pressure level of 75Pa in all patients, in both nostrils, with and without vasoconstrictor, we observe a positive value of 1434cm3/s, which after being divided by 32 analyses, four in each patient, results in a measure of 44.81cm3/s of increase on average. Under the pressure of 150Pa, we obtained an increase of 2676cm3/s, which, after being divided by 32 analyses, shows an average of 83.62cm3/s of increase. Under the pressure of 300Pa, we obtained a total increase of 4200cm3/s, which divided by 32 measures in the 8 patients, results in an average increase of 131.25cm3/s in each measure. It was concluded that nasal airflow improves more after pyriform plasty as the inspiratory pressure increases, for instance, in physical exercise.

Statistical analysis using the box plot charts showed that the median (50th percentile) was always increased postoperatively in relation to the preoperative period. With 75Pa of resistance in the right nostril, with vasoconstrictor, nasal flow increase was observed, with a statistically significant difference. Statistically significant differences also occurred with 150Pa of resistance in the right nostril with vasoconstrictor, and with a 300Pa of resistance, statistically significant differences were observed in the right nostril, with vasoconstrictor, and in the left nostril without vasoconstrictor.

The NOSE questionnaire results also showed a decrease in values with a statistically significant difference.

This study should be followed by further research, aiming to support this thesis, including other pre-and postoperative evaluation techniques, which may justify other investigations, such as evaluations with CT and volumetric measurement of the nasal cavity through an appropriate software.

Conclusion

There was nasal airflow improvement after the pyriform plasty, when compared to the preoperative nasal airflow.

Conflicts of interest

The authors declare no conflicts of interest.

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Please cite this article as: Sofia OB, Castro Neto NP, Katsutani FS, Mitre EI, Dolci JE. Evaluation of pre- and post-pyriform plasty nasal airflow. Braz J Otorhinolaryngol. 2018;84:351–9.

Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.

Copyright © 2017. Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial
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Brazilian Journal of Otorhinolaryngology (English Edition)

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