British Journal
of Plastic
Surgery (1976), 7.9, 132-133
PHARYNGOPLASTY IN ATROPHIC RHINITIS By A. J. C. HUFFSTADT, M.D.,1 and P. E. HOEKSEMA, M.D.2 From the Departments
ofPlastic
Surgery’ and Otorhinolary~ology,2 Academisch Ziekenhuis, Groningen, Oostersingel59, The Netherlands
CHRONICatrophic rhinitis, or ozaena, is a syndrome of still obscure aetiology which causes much psychosocial suffering to the patients and their relations and acquaintances. The main characteristics are atrophy of the mucosa of the nose and pharynx, formation of crusts which are diflicult to remove and a repulsive smell. It may become manifest at any age and spontaneous cure is very rare. Local applications are of little avail and treatment has been mainly surgical, based on the principle that reduction of the nasal airway would reduce the drying effect of inspired air which is assumed to be an important factor. The wide variety of implants inserted submucosally for this purpose include acrylic, polyethylene, silicone rubber, Teflon, dermo-fat, cartilage and bone. Although satisfactory results have been achieved many implants are lost because of the thin atrophic mucosa. Young (1967) reported on his technique of raising skin flaps inside the nostrils and stitching them together in such a way that full closure of the air passage is achieved. The result is complete cure of the atrophic rhinitis with normal appearance of the mucosa. Children will accept such a blocked nose reasonably well but most adults experience a sense of suffocation and a very unpleasant dry mouth from the constant mouth breathing. Young (1971) later wrote that after a period of closure the nose might be re-opened again without recurrence of the disease. He did not indicate the exact interval but Shah et al. (1974) recommend a complete closure period of 2 years and, in the case of a partial closure, a period of 5 years before re-opening the airway. REDUCING NASALAIRFLOWWITHA PHARYNGEAL FLAP Since adults find total closure intolerable, since partial occlusion of the nostrils is d8icult to achieve with precision and since we have had experience of more than 3oo pharyngeal flap pharyngoplasties in the treatment of hyper-rhinolalia, we felt that a similar operation might provide a satisfactory compromise between correction of the ozaena and the minimum nasal airflow necessary for comfort. Our pharyngoplasty makes use of a modified Rosenthal, i.e. caudally based, pharyngeal flap; it is cut as wide as possible and is designed in a position that is as cranial as possible. The donor defect is left open (HulIstadt et al., 1970). In spite of the width of the flap, blockage of the air passage is rarely encountered in clefi palate cases. In the rhinitis patients, however, total blockage of the nasal airway occurred frequently. The technique was therefore changed; the width of the flap is nowadays never more than three-quarters of the total pharyngeal width. MATERIAL Since 1969,20 patients, 12 of them female, with atrophic rhinitis have undergone a pharyngeal flap operation. The youngest was 8 years old, the oldest 62; the average age was 37. 132
PHARYNGOPLASTY
IN ATROPHIC
RHINITIS
I33
RESULTS
It is not possible to present the results numerically. Clinical examination may demonstrate reduction in crusting and fetor while the patient may be much more concerned about the reduction in nasal airflow, and the degree of compromise achieved depends on the individual. Three patients had no improvement at all. The other 17 all experienced a most welcome disappearance of the foul smell although some of them still produced too much mucus and crusts which they were able to control quite well with saline nose baths. In 2 patients the ozaena cleared up completely with a normal appearance of the mucosa, but their difhculties with the impaired nasal airway made it necessary to reduce the width of the flap at a second operation. This was followed by more comfortable breathing, but slight symptoms of the atrophic rhinitis recurred. The most instructive result was seen in a 56-year-old lady who was socially absolutely impossible because of her ozaena; she slept in a separate room from her husband. After the pharyngoplasty the disorder improved so much that she could again sleep in the conjugal bedroom. But 6 months later she started snoring so heavily that, for that reason alone, life became impossible again and she asked to have the pharyngeal flap undone. The flap was severed I year after the first operation. Six weeks later, she started to produce purulent discharge and an awful smell again. The snoring changed its character but did not disappear. DISCUSSION
The first IO patients were treated with the wide flap we use for rhinolalia. All of them had some difIiculty in nasal breathing. Next, the original Rosenthal (1924) method with a narrow flap and closure of the donor area was performed but it was obvious that this was very much less effective than the wide flap. A flap of about three-quarters width of the dorsal pharyngeal wall is now used as a compromise between an effective reduction of the nasal airway and reasonable breathing. SUMUARY
A caudally based pharyngeal flap has been used to treat atrophic rhinitis in patients. REFERENCES
HIJFFSTADT, A. J. C., BORGHOUTS, J. M. H. M. snd MOOLENAAR-BIJL, A. J. (1970). Operative treatment of rhinolalia: a review of 139 pharyngoplasties. British Journal of Plastic surge% 23, 1%‘. ROSENTHAL,W. (1924). Zur Frage der Craumenplastik. Zentralbl. fiir Chirurgie, 51, 1621. SHAH, J. T., KARNIK, P. P., CHITALE,A. R. and NADKARNI, M. S. (1974). Partial or total closure of the nostrils in atrophic rhinitis. Archives of Otolaryngoscopy, IOO, 196. YOUNG,A. (1967). Closure of the nostrils in atrophic rhinitis. Journal of Laryngology and _ Otology, 81, 515. YOUNG, A. (1971). Closure of the nostrils in atrophic rhinitis. 3ournal of Laryngology and Otology, 85, 715.
20
of Plastic
Surgery (1976), 7.9, 132-133
PHARYNGOPLASTY IN ATROPHIC RHINITIS By A. J. C. HUFFSTADT, M.D.,1 and P. E. HOEKSEMA, M.D.2 From the Departments
ofPlastic
Surgery’ and Otorhinolary~ology,2 Academisch Ziekenhuis, Groningen, Oostersingel59, The Netherlands
CHRONICatrophic rhinitis, or ozaena, is a syndrome of still obscure aetiology which causes much psychosocial suffering to the patients and their relations and acquaintances. The main characteristics are atrophy of the mucosa of the nose and pharynx, formation of crusts which are diflicult to remove and a repulsive smell. It may become manifest at any age and spontaneous cure is very rare. Local applications are of little avail and treatment has been mainly surgical, based on the principle that reduction of the nasal airway would reduce the drying effect of inspired air which is assumed to be an important factor. The wide variety of implants inserted submucosally for this purpose include acrylic, polyethylene, silicone rubber, Teflon, dermo-fat, cartilage and bone. Although satisfactory results have been achieved many implants are lost because of the thin atrophic mucosa. Young (1967) reported on his technique of raising skin flaps inside the nostrils and stitching them together in such a way that full closure of the air passage is achieved. The result is complete cure of the atrophic rhinitis with normal appearance of the mucosa. Children will accept such a blocked nose reasonably well but most adults experience a sense of suffocation and a very unpleasant dry mouth from the constant mouth breathing. Young (1971) later wrote that after a period of closure the nose might be re-opened again without recurrence of the disease. He did not indicate the exact interval but Shah et al. (1974) recommend a complete closure period of 2 years and, in the case of a partial closure, a period of 5 years before re-opening the airway. REDUCING NASALAIRFLOWWITHA PHARYNGEAL FLAP Since adults find total closure intolerable, since partial occlusion of the nostrils is d8icult to achieve with precision and since we have had experience of more than 3oo pharyngeal flap pharyngoplasties in the treatment of hyper-rhinolalia, we felt that a similar operation might provide a satisfactory compromise between correction of the ozaena and the minimum nasal airflow necessary for comfort. Our pharyngoplasty makes use of a modified Rosenthal, i.e. caudally based, pharyngeal flap; it is cut as wide as possible and is designed in a position that is as cranial as possible. The donor defect is left open (HulIstadt et al., 1970). In spite of the width of the flap, blockage of the air passage is rarely encountered in clefi palate cases. In the rhinitis patients, however, total blockage of the nasal airway occurred frequently. The technique was therefore changed; the width of the flap is nowadays never more than three-quarters of the total pharyngeal width. MATERIAL Since 1969,20 patients, 12 of them female, with atrophic rhinitis have undergone a pharyngeal flap operation. The youngest was 8 years old, the oldest 62; the average age was 37. 132
PHARYNGOPLASTY
IN ATROPHIC
RHINITIS
I33
RESULTS
It is not possible to present the results numerically. Clinical examination may demonstrate reduction in crusting and fetor while the patient may be much more concerned about the reduction in nasal airflow, and the degree of compromise achieved depends on the individual. Three patients had no improvement at all. The other 17 all experienced a most welcome disappearance of the foul smell although some of them still produced too much mucus and crusts which they were able to control quite well with saline nose baths. In 2 patients the ozaena cleared up completely with a normal appearance of the mucosa, but their difhculties with the impaired nasal airway made it necessary to reduce the width of the flap at a second operation. This was followed by more comfortable breathing, but slight symptoms of the atrophic rhinitis recurred. The most instructive result was seen in a 56-year-old lady who was socially absolutely impossible because of her ozaena; she slept in a separate room from her husband. After the pharyngoplasty the disorder improved so much that she could again sleep in the conjugal bedroom. But 6 months later she started snoring so heavily that, for that reason alone, life became impossible again and she asked to have the pharyngeal flap undone. The flap was severed I year after the first operation. Six weeks later, she started to produce purulent discharge and an awful smell again. The snoring changed its character but did not disappear. DISCUSSION
The first IO patients were treated with the wide flap we use for rhinolalia. All of them had some difIiculty in nasal breathing. Next, the original Rosenthal (1924) method with a narrow flap and closure of the donor area was performed but it was obvious that this was very much less effective than the wide flap. A flap of about three-quarters width of the dorsal pharyngeal wall is now used as a compromise between an effective reduction of the nasal airway and reasonable breathing. SUMUARY
A caudally based pharyngeal flap has been used to treat atrophic rhinitis in patients. REFERENCES
HIJFFSTADT, A. J. C., BORGHOUTS, J. M. H. M. snd MOOLENAAR-BIJL, A. J. (1970). Operative treatment of rhinolalia: a review of 139 pharyngoplasties. British Journal of Plastic surge% 23, 1%‘. ROSENTHAL,W. (1924). Zur Frage der Craumenplastik. Zentralbl. fiir Chirurgie, 51, 1621. SHAH, J. T., KARNIK, P. P., CHITALE,A. R. and NADKARNI, M. S. (1974). Partial or total closure of the nostrils in atrophic rhinitis. Archives of Otolaryngoscopy, IOO, 196. YOUNG,A. (1967). Closure of the nostrils in atrophic rhinitis. Journal of Laryngology and _ Otology, 81, 515. YOUNG, A. (1971). Closure of the nostrils in atrophic rhinitis. 3ournal of Laryngology and Otology, 85, 715.
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