Saddle nose deformity and septal perforation in granulomatosis with polyangiitis

Abstract

Background Patients who have granulomatosis with polyangiitis (GPA, syn. M. Wegener) often develop an external nose deformity which may have devastating psychological effects. Therefore, reconstruction of nasal deformities by rhinoplasty may become necessary to achieve a normal appearance. Objective of review The aim of this systematic review was to investigate the efficacy and safety of surgical reconstruction in external nasal deformities and septal perforation in GPA patients. Search strategy A systematic literature search with defined search terms was performed for scientific articles archived in the MEDLINE‐Database up to 10 June 2016 (PubMed Advanced MEDLINE Search), describing management of cases or case series in GPA patients with saddle nose deformity and/or septal perforation. Results Eleven of 614 publications met the criteria for this analysis including 41 GPA patients undergoing external nasal reconstruction and/or septal reconstruction with a median follow‐up of 2.6 years. Overall, saddle nose reconstruction in GPA patients is safe even if an increased rate of revision surgery has to be expected compared with individuals without GPA undergoing septorhinoplasty. Most implanted grafts were autografts of calvarial bone or costal cartilage. For septal perforation reconstruction, few studies were available. Therefore, based on the available data for surgical outcomes, it is impossible to make evidence‐based recommendations. All included GPA patients had minimal or no local disease at the time of reconstructive surgery. Therefore, the relationship between disease activity and its impact on surgical outcomes remains unanswered. The potential impact of immune‐modulating medications on increased complication rates and the impact of prophylactic antibiotics are unknown. Conclusions This study systematically reviews the efficacy and safety of surgical reconstruction of external nasal deformities in GPA patients for the first time. Saddle nose reconstruction in GPA patients with minimal or no local disease is a safe procedure despite an increased rate of revision surgery. Further research is required regarding the impact of antibiotic prophylaxis, immune‐modulating therapy, long‐term outcomes and functional outcomes measured with subjective and objective parameters.

The role of surgery in antineutrophil cytoplasmic antibody–associated vasculitides affecting the nose and sinuses: A systematic review

“…As a general rule, the severity of the saddle nose deformity guides the method of reconstruction and can range from isolated dorsal augmentation onlay techniques, to the use of extended spreader graft techniques when length also needs augmenting 31 and to finally a two-dimensional L-shaped strut technique when length and projection require augmentation. 29 …”

“…Systematic reviews demonstrate that saddle nose reconstruction in GPA patients with minimal or no local disease is a safe procedure and that L-strut grafts appear to be a more robust technique in the setting of GPA. 29 , 40 The risk of complication decreases with the use of a L-shaped strut reconstruction technique when compared to reconstruction using multiple smaller grafts. 40 The L-strut also affords better stability which resists the resultant scarring and contracture caused by surgery, whereas the placement of smaller and less secure grafts does not offer this stability.…”

Refinements in Saddle Nose Reconstruction

“…In a systemic review article, good results are reported for calvarial bone and costal cartilage when it comes to external nasal reconstructions for GPA. 21 In general, saddle nose correction is safe and effective in cases of quiescent GPA, and surgery does not appear to either induce a flare-up or accelerate the course of this condition. 22,23 In relation to relapsing polychondritis, surgery has traditionally only been recommended in cases of severe respiratory or cardiac complications, and there has been no study regarding the effectiveness of rhinoplasty with minimal disease activities.…”

Upper respiratory tract involvement in patients with ANCA-associated vasculitis

“…1) [16]. Одновременно с развивающейся седловидной деформацией кожа носа может приобретать синева-тую окраску, что связано с нарушением кровоснабжения этой области [29].…”