30 Rhinoplasty in Patients with Systemic Diseases
There are various systemic diseases that have nasal and mucosal manifestations and may lead to a change in the external shape of the nose. Thus, the preoperative endonasal examination should include attention to possible septal perforations and particularly mucosal lesions, as they may be an initial manifestation of a previously undiagnosed systemic disease. 1 Especially in patients with a saddle nose deformity, it is important to look for a possible underlying disease and treat it before proceeding with reconstructive surgery. Some conditions would contraindicate operative treatment. Examples are malignant diseases such as primary nasal NK/T cell lymphoma (due to the severity of the underlying disease) and relapsing perichondritis (due to the recurring nature of the disease).
Systemic diseases that may cause nasal changes include infectious diseases such as tuberculosis or leprosy as well as immune deficiency syndromes (HIV), malignancies, and chronic inflammatory bowel diseases (Crohn disease, ulcerative colitis). 2 , 3 Other important diseases that may have nasal manifestations are granulomatous diseases (sarcoidosis), various forms of vasculitis (Wegener disease, Churg-Straus syndrome), 4 and relapsing polychondritis. 5 , 6 The possibility of cocaine abuse should be considered when the history is taken, as it may lead to mucosal granulomas.
In many of these systemic diseases, a cursory preoperative examination may reveal only mild mucosal lesions whose significance is not fully appreciated. But these lesions may lead to postoperative wound healing problems and even external deformities of the nose. If a systemic disease is suspected preoperatively, further tests should be done to avoid a failed operation and especially to direct the prompt treatment of a potentially severe systemic illness. 7 – 9 The workup should normally consist of serologic blood tests (pANCA, cANCA, ANA, IgG, IgE, etc.), biopsies with histologic evaluation, and imaging studies (chest radiograph, joint imaging, etc.). Ideally, the candidate for a reconstructive rhinoplasty should be in a state of full remission that is supported by long-term compliance with prescribed medications.
Case 48
Introduction
Ten years ago the patient, now 50 years of age, suffered an episode of suppurative rhinitis marked by the rapid development of a saddle nose deformity and perforated septum. Initially she was suspected of having Wegener vasculitis, but nasal mucosal biopsies did not confirm this. There was evidence of nonspecific rhinitis and perichondritis. With a presumptive diagnosis of p-ANCA-associated vasculitis, the patient was treated medically with prednisolone, acathioprin Endoxan, and MTX. She expressed a desire to have both the function and appearance of her nose improved.
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