Functional Rhinoplasty

Patient Satisfaction in Functional Rhinoseptoplasty: The Role of Nonsurgical Factors

Functional rhinoseptoplasty (FRS) is a surgical procedure with both functional and aesthetic impacts, significantly affecting patients' quality of life. The influence of nonsurgical factors on FRS outcomes remains a debated topic in the literature. For instance, some authors deny the long-term impact of gender, age, inferior turbinectomy, or active smoking on the results. The rhinoplasty outcome evaluation (ROE) questionnaire is a useful tool for assessing patients' satisfaction once submitted to this surgery.To evaluate the subjective impact of nonsurgical factors on the long-term outcomes of FRS.The authors conducted a retrospective study of all patients who underwent FRS at a tertiary hospital between 2019 and 2023. Patients with less than 1 year of postoperative follow-up were excluded. The ROE questionnaire was used to quantify subjective surgical satisfaction. Various variables were analyzed, including previous nasal pyramid trauma, age, known hematologic pathology, psychiatric history, allergic rhinitis, smoking habits, and inferior turbinectomy. Statistical calculations were performed using the Kruskal-Wallis formula.The sample included 75 patients with an average age of 33.4 years, mostly female (51%; n = 38). The average ROE score in the sample was 79.6%. Thirty-eight point seven percent (n = 29) of the procedures were performed after nasal pyramid trauma, with these patients reporting higher ROE scores than others (85.78% in the trauma group; 75.6% in the nontrauma group; p-value = 0.01394). Even though no statistical correlation was demonstrated, ROE scores were also higher in patients with allergic rhinitis (82.1% vs. 78.1% on the healthy group), psychiatric disorders (85.8% vs. 75.6% on the healthy group), hematological disorders (91.7% vs. 78.9% on the healthy group), nonsmokers (81.7% vs. 74.0% on smokers), younger patients (81.7% vs. 76.8% on patients older than 33.4 years) and patients that underwent inferior turbinectomy (81.0% vs. 75.9%).This study established a correlation between the subjective degree of surgical satisfaction and previous nasal trauma in patients undergoing FRS.

Postoperative Pain and Perioperative Antibiotic Management in Functional Rhinoplasty

Post-rhinoplasty pain control should use a multimodal regimen. Evidence suggests decreasing routine prescriptions of narcotics is reasonable for most individuals, and acetaminophen and nonsteroidal antiinflammatory drug combinations may be equivalent to as-needed opioids for postsurgical pain management. Preoperative pain counseling is important to set post-rhinoplasty pain expectations and reduce opioid use. A single intravenous dose of prophylactic antibiotics before incision is sufficient for most cases of functional rhinoplasty. Additional considerations are given to complex revision cases, use of allogenic grafts or implants, external osteotomies, or patients with immunosuppression or at risk of endocarditis.

Complications in Functional Rhinoplasty Related to Cartilage Graft Source

Background: Functional rhinoplasty often relies on repurposed cartilage for nasal framework grafting. Objective: To compare complications in functional rhinoplasty associated with use of autologous versus fresh frozen cadaveric rib cartilage (FFCR). Methods: This retrospective cohort study included patients who underwent functional rhinoplasty from 2017 to 2022 with 6 months of documented follow-up. The primary outcome measure was need for revision rhinoplasty. Secondary outcomes were infection and persistent nasal obstruction without revision surgery. Chi-squared and Fisher's exact tests were used for univariate analysis, and multivariable logistic regression was used to evaluate the relationship between revision surgery and covariates. Results: 259 patients (average age: 43.1 ± 16.2, 185/259 female [71.4%]) underwent functional rhinoplasty with an average of 12.3 months (range: 6-54 months) of documented follow-up. A total of 58 (22.4%) cases utilized FFCR for grafting. Overall, 15 (5.8%) patients required revision rhinoplasty (8/201 [4.0%] autologous versus 7/58 [12.1%] FFCR), while 17 (6.6%) had persistent postoperative nasal obstruction without further surgery and 12 (4.6%) had an infection requiring prescribed oral antibiotics or drainage. Compared to autologous cartilage, there was a significant association between the use of FFCR with revision rhinoplasty on logistic regression (p = 0.024, odds ratio: 4.0 [95% confidence interval: 0.17-2.61]) but not with postoperative infection (p = 0.101) or persistent nasal obstruction (p = 0.187). Conclusion: These findings suggest increased rates of revision surgery associated with the use of FFCR in functional rhinoplasty. In the setting of insufficient autologous cartilage, tailored discussions should take place regarding the risks and benefits of potential supplemental graft material.

The Effect of Functional Rhinoplasty on Quality of Life: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of the study was to comprehensively review the effect of functional rhinoplasty on quality of life.

METHODS

Eligible studies before December 2022 were identified by searching PubMed, Ovid, and Embase databases. The meta-analysis was performed with Stata. Outcomes included NOSE, SNOT-22 scores, VAS of obstruction, and ROE.

RESULTS

Sixteen studies, involving a total of 971 patients, were included. Meta-analysis showed that functional rhinoplasty statistically reduced the NOSE, SNOT-22 scores, and VAS of obstruction and statistically increased the ROE score of patients.

CONCLUSION

Functional rhinoplasty could statistically significantly improve quality of life of patients. However, given the number and quality of included research, further thorough studies with a larger sample size of high-quality studies need to be conducted.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Functional Rhinoplasty

The nose is composed of intricate intranasal anatomy to serve its sophisticated functions. Although it only occupies a small area, it is the central focal point of the face and demands the highest level of understanding of the delicate interplay of form and function. Functional rhinoplasty, as opposed to aesthetic rhinoplasty, primarily aims to enhance nasal breathing and olfaction without altering the nose's appearance. The goal of this study is to describe the anatomy and physiology of the nose as well as the pathophysiology of nasal obstruction and the surgical approaches available for functional rhinoplasty. Whether when performed alone or combined with cosmetic rhinoplasty, functional rhinoplasty is a procedure that can bring significant benefits and improve the quality of life of our patients. Understanding nasal anatomy and physiology is key for successful management and outcomes. To provide optimal treatment for the patients, plastic surgeons must be familiarized with various techniques that have been documented.

Clinical Efficacy Analysis of Functional Rhinoplasty Assisted by Nasal Endoscopy

OBJECTIVE

To analyze the clinical effect of endoscopy-assisted functional rhinoplasty.

METHODS

Endoscopy-assisted functional rhinoplasty was performed in all patients. Deviated nasal septum was corrected, nasal septum cartilage graft was prepared through open access under the assistance of endoscopy, the nasal frame structure was adjusted with the endoscopy-assisted rhinoplasty combined with middle and inferior turbinoplasty, and the patient's nasal ventilation function and external nose cosmetology were restored. Visual Analogue Scale (VAS), Nasal Obstruction Symptom Evaluation (NOSE), nasal acoustic reflex, and nasal resistance were examined preoperatively and 6 months postoperatively. Rhinoplasty Outcome Evaluation (ROE), nasal appearance deviation value, and morphological measurement of the external nose were used to assess the external nasal appearance. Finally, postoperative satisfaction was used for overall evaluation.

RESULTS

In terms of nasal ventilation evaluation, the VAS and NOSE scores of nasal obstruction decreased significantly at 6 months after the operation compared with that before the operation (1.96 ± 0.84 vs 6.68 ± 1.28, 4.25 ± 1.80 vs 12.25 ± 2.50; P < .05). Among the objective indexes, MCA1, MCA2 and NV5 were significantly increased whereas RT, MCA1a/MCA1b, MCA2a/MCA2b, MD1a/MD1b, and MD2a/MD2b were significantly decreased compared with those before the operation (P < .05). The MD1 and MD2 levels before and after operation had no significant differences (P > .05). In the evaluation of external nose morphology, postoperative ROE was significantly increased, and the deviation value of nasal appearance was significantly decreased [(16.93 ± 2.61 vs 10.64 ± 3.01), (1.46 ± 1.11 mm vs 5.72 ± 2.30 mm), P < .05]. In terms of postoperative patient satisfaction: 26 cases (92.9%) were very satisfied with nasal ventilation function, 2 cases (7.1%) were satisfied with nasal ventilation function, 24 cases (85.7%) were very satisfied with nasal appearance, and 4 cases (14.3%) were satisfied with nasal appearance.

CONCLUSIONS

Nasal endoscopy-assisted functional rhinoplasty can improve the nasal ventilation function and external nasal morphology at the same time. Moreover, its clinical effect is good, and the patient satisfaction is high.

Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Intraoperative nerve blocks have shown promise in managing pain after nasal surgery. The purpose of this systematic review and meta-analysis was to analyze existing level I and II evidence on intraoperative nerve blocks in nasal surgery to optimize postoperative recovery.

Methods

The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability.

Results

Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001).

Conclusions

These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.

The RhinoCEROS Guidelines: A Practical Tool for Reporting Nasal Anatomy on Computed Tomography Pertaining to Rhinoplasty

Cone-beam computed tomography (CT) is gaining popularity worldwide due to an increasingly diffuse and affordable in-office availability. It is becoming more commonplace for rhinoplasty surgeons to utilize this imaging as tool for preoperative assessment; however, there is inconsistency among radiologists commenting on specific structures of the nose or nasal cavity as there is currently no standardized reporting protocol. The goal of this article is to present clear guidelines for radiologists to report relevant nasal anatomy in the context of preoperative rhinoplasty evaluation. We have proposed the RhinoCEROS Guidelines, which stands for: Rhinoplasty Cephalometric Evaluation for Radiologic pre-Operative Systematization. This guideline highlights the primary aspects of nasal anatomy on CT that affect rhinoplasty outcomes and will provide radiologists with a straightforward template for reporting this increasingly popular use for CT scan.

Trends of rhinoplasty research in the last decade with bibliometric analysis

Background

As rhinoplasty (RP) with different requirements is becoming more and more popular in the latest decade, this study aims to quantitatively and qualitatively explore the trends in RP research, depict research hotspots, and point out the future direction with a bibliometric analysis.

Methods

All RP literature studies in the last decade (from 2012 to 2021) were retrieved from the Web of Science Core database. Annual output, institutions, authors, journals, and most-cited literature studies were analyzed by bibliometric tools, including CiteSpace, bibliometric online platform, bibliometrix R language kit, BICOMB, and gCLUTO.

Results

A total of 2,590 RP research studies dated between 2012 and 2021 were included according to our criterion. As for the country, the United States, Turkey, and Korea maintained the top three in RP research. As for the institutions, the University of California, Irvine, Stanford University, and University of Ulsan ranked top three in RP research publications based on article counts. Professor Rhorich RJ, Most SP, and Jang YJ were the most contributed authors according to article counts and citation number. The top journals were The Plastic and Reconstructive Surgery, JAMA Facial Plastic Surgery, and Aesthetic Surgery Journal. The 10 most-cited literature studies were also listed explicitly in this study. Finally, biclustering analysis on the most frequent keywords were conducted which helped us to identify seven hotspot clusters in RP research.

Conclusions

We comprehensively summarized the publication information of RP literature studies in the past decade, highlighted the current status and trends over time, and provide guidance for in-depth research direction on RP for the future.

Understanding Nasal Valve Compromise in Nasal Airway Obstruction: A New Classification System

OBJECTIVES

A key aspect of rhinoplasty is integrity of nasal valves area because of its fundamental role in patent nasal airway. furthermore, nasal obstruction is a dominant feature in patient with nasal valves dysfunction (NVD) which can be devastating outcome after rhinoplasty.

METHODS

Nonetheless, NVD has been widely investigated regarding their etiologies and management. However, it has been assumed that the anatomical complexity and interplay between its structures causing a confusion for a beginner surgeon to diagnose and treat NVD. This study was approved by the institutional review board of Chosun University Hospital, Gwangju, Korea (2022-11-005).

RESULTS

To date, the lack of consensus on nasal valve pathologies and corrective procedures has led to its underestimations during analysis and management. As result, we proposed a classification system based on its affected anatomical part, location, and their management. Thus, implementing a classification system for NVD will help guide the practice of rhinoplasty and introduce a more structured approach.

CONCLUSION

This approach will prove useful in expanding our understanding of how important to locate the pathology of NVD and apply the most relevant management options, particularly for a beginner surgeons.

LEVEL OF EVIDENCE

V.

Comparative Effectiveness of Cartilage Grafts in Functional Rhinoplasty for Nasal Sidewall Collapse

Objective: To compare the patient-reported outcomes among patients with nasal obstruction undergoing two rhinoplasty techniques to a control group. Methods: Prospective longitudinal study in a university-based tertiary care medical center. All patients undergoing functional septorhinoplasty for correction of lateral wall insufficiency between October 2015 and March 2019 were included; n = 704, mean age (standard deviation) 39.0 (15.4) years, 52.7% females. Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) and FACE-Q subscales pre- and postoperatively. Patients were divided into three cohorts: spreader and lateral crural strut (LCS) grafts (n = 141), spreader and alar rim (AR) grafts (n = 104), and the control spreader grafts alone (n = 218). Results: The median NOSE scores at last postoperative visit were improved from baseline (p < 0.001) for all cohorts. The FACE-Q nasal satisfaction median scores also improved postoperatively in all cohorts, AR, LCS, and spreader, respectively (p = 0.001, p < 0.001, and p < 0.0001). Conclusions: There was no detectable difference in the improved subjective nasal function, nor adverse aesthetic outcomes in the patients with lateral wall insufficiency treated with functional rhinoplasty techniques in this study.

Reduction Rhinoplasty Re-Endorsed: When Conservative and Measured

Reduction rhinoplasty has been widely criticised and dismissed due to the current preference for structural rhinoplasty. The criticism is related to airway compromise and secondary structural deformities, both early and late, due to overzealous resection. This two-year study attempted to prospectively assess the risk of airway and structural problems following reduction rhinoplasty in 30 consecutive patients. The findings showed no statistically significant difference either in the NOSE score (subjective sense of breathing) or in nasal valving (objective observations), at the 3-month follow-up. Subsequent 12-month telephone reviews revealed no change in the patients' functional or aesthetic outcomes. There was a 3% structural complication rate (requiring secondary surgery) and a 20% rate for further refining reduction surgery. The findings confirmed the author's impression that conservative, measured reduction rhinoplasty, performed with due consideration to preserving the nasal supportive framework, is a technique well worth endorsing with confidence to reduce the disproportionately large nose. Contemporary surgeons need not feel obliged to only use the more complex later-developed structural rhinoplasty techniques.

Middle Vault Changes After Humpectomy by Spare Roof Technique Versus Component Dorsal Hump Reduction

Objectives: To compare the effect of two different humpectomy techniques in the internal nasal valve (INV) angle in human anatomic specimens. Methods: Seven human anatomic specimens (14 heminoses) were included. A strip of subdorsal septal cartilage was removed and, in each nose, the right side of the middle roof lied intact over and was sutured to the septal cartilage (spare roof technique [SRT]), whereas in the left side the upper lateral cartilage was folded and sutured to the septal cartilage (component dorsal hump reduction [CDHR]). The INV angle was measured pre- and postoperatively. Results: Mean age of the specimens was 69.86 (60-80) years. Five were female. CDHR resulted in a mean change of +1.71 ± 3.12° (p = 0.197), +0.62 ± 6.89° (p = 0.817) and +6.97 ± 6.84° (p = 0.036) after resection of 2, 4, and 6 mm of septal cartilage, respectively. SRT resulted in a mean change of +1.27 ± 2.37° (p = 0.207), +6.89 ± 1.19° (p < 0.001), and +12.55 ± 1.79° (p < 0.001) after resection of 2, 4, and 6 mm of septal cartilage, respectively. In SRT, the amount of septal cartilage resection presented a significant correlation with change in INV angle (r = 0.813, p < 0.001). Conclusions: In this human anatomic study, SRT significantly increased INV angle.

Correction of Septal Perforation/Nasal Airway Repair

Rhinoplasty is a double-edged sword regarding the functional nasal airway; it can enhance and improve the nasal airway if done properly, and can severely compromise the nasal airway if not done properly. The composition of the nasal airway includes the internal and external nasal valves, nasal septum, and inferior turbinates. Each of these areas can be addressed by several techniques, described in the body of the text. Nasal septal perforation is another potential complication that may result from septal surgery, which has nonsurgical and surgical methods to treat, and is also described in the body of the text.

Nasal Obstruction and Rhinoplasty: A Focused Literature Review

BACKGROUND

There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods.

METHODS

A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies.

RESULTS

The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies.

CONCLUSIONS

Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Normative data for the Nasal Obstruction Symptom Evaluation Scale in the general Australian population

BACKGROUND

Recent changes to the Australian Medicare Benefits Scheme have introduced the NOSE Score as a criteria threshold for funding rhinoplasty. On review of the literature, however, there is minimal normative Nasal Obstruction Symptom Evaluation (NOSE) score data to provide context for these changes.

METHODS

Participants were recruited according to the general Australian population distribution of age (18-65 years), gender and geographical locations using the market research company Pureprofile. The data included demographic details, risk factors for nasal obstruction such as smoking, obstructive sleep apnoea, use of continuous positive airway pressure, history of nasal trauma, operations to the nose and a history of cleft lip/palate and each participant completed the NOSE Scale. Analysis of data included descriptive statistics, independent t-tests and one-way analysis of variances to assess differences in NOSE scores between risk factors.

RESULTS

The NOSE score was completed by 247 males and 255 females with a mean age of 41(±13.39) years. The cohort had a mean NOSE score of 16 (±18.89) with a range from 0 to 95. A total of 48 respondents had a NOSE score greater than the Medicare threshold of >45. Cleft lip/palate, obstructive sleep apnoea and continuous positive airway pressure use were shown to have a statistically significant impact on NOSE score while other variables including body mass index, gender, smoking, location and other surgery to the nose were not shown to significantly impact results.

CONCLUSIONS

This study found that 9.6% of the general Australian population would have a NOSE score >45 and qualify for the Medicare Benefits Scheme rhinoplasty benefit.

The miniature lateral crural strut graft: Efficacy of a novel technique in tip plasty

OBJECTIVES/HYPOTHESIS

To describe a novel technique for tip plasty and determine its efficacy using validated patient-reported outcome measures and objective measures.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study was carried out at a tertiary center. Patients undergoing tip plasty using the miniature lateral crural strut grafts (mini-LCSG) in cosmetic/combined rhinoplasty between January 2016 and August 2019 with available outcome measures were included. We used the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), Nasal Obstruction Symptom Evaluation (NOSE) scores, visual analog scale: functional and cosmetic, and lateral wall insufficiency (LWI) grades.

RESULTS

Among 52 patients, 33 were included; 26 had cosmetic whereas seven had combined functional and cosmetic rhinoplasty, with a follow-up up to 3 years. Both cosmetic and combined subjects showed significant improvement in SCHNOS-Cosmesis (C) scores (-57.31 ± 1.79, P < .001 and - 53.57 ± 8.39, P < .001, respectively) and zone 1 LWI (P < .05, both sides). SCHNOS-Obstruction (O) and NOSE scores showed significant decrease among subjects undergoing combined rhinoplasty only (-55.36 ± 18.58, P < .004, and - 53.93 ± 15.99, P < .003, respectively). With specific regard to tip cosmesis, the mean SCHNOS-6 (item 6 of the SCHNOS questionnaire for tip cosmesis) showed significant improvement (-2.61, P < .001).

CONCLUSIONS

The mini-LCSG is a novel modification for tip plasty that improves tip cosmesis and symmetry, both subjectively and objectively without compromising nasal function.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2581-2588, 2020.

Finesse in Caucasian Endonasal Rhinoplasty: The S.O.F.T. Concept

The nasal anatomy of Caucasian people includes thin skin, limited soft tissue volume, a high dorsum, strong cartilaginous framework, and narrow elliptical nasal inlets. A smooth dorsal contour, a well-defined tip, a naturally soft-feeling tip, and a functionally patent nasal valve constitute key objectives for Caucasian rhinoplasty. The author's focus on minimal-impact surgery has resulted in multiple novel techniques, embedded in a coherent algorithmic concept termed the S.O.F.T. (surgery and ongoing care free of trauma) concept. The foundation is the endonasal operation for the entire spectrum of primary and secondary deformities and maximal preservation of anatomic structures.

Can Functional Nasal Surgery Treat Chronic Headaches? A Systematic Review

BACKGROUND

Nasal surgery is one of the most common operations performed by plastic surgeons. The link between functional nasal surgery and improvement in nasal breathing is well established, but there are other metrics that have been shown to improve as a result of anatomical correction of the nose. Current literature suggests that surgery to remove nasal mucosal contact points can reduce symptoms in chronic headache patients. The authors conducted a systematic literature review to determine the validity of this hypothesis.

METHODS

A systematic search of the literature was performed using the terms "headache," "rhinogenic headache," "contact point," "migraine," and "surgery/endoscopy."

RESULTS

The authors identified 39 articles encompassing a total of 1577 patients who underwent surgery to treat mucosal contact point headaches. Septoplasty and turbinate reduction were the most commonly performed procedures, often in combination with endoscopic sinus surgery. Analysis of the combined data demonstrated improvement in the reported severity of patient symptoms, with 1289 patients (85 percent) reporting partial or complete resolution of headaches postoperatively. Average visual analogue scale scores and number of headache days in patients undergoing nasal surgery were reduced from 7.4 ± 0.9 to 2.6 ± 1.2 (p < 0.001) and 22 ± 4.3 days to 6.4 ± 4.2 days (p = 0.016), respectively. Improvement in headache symptoms was significantly associated with a positive response to preoperative anesthetic testing, and with inclusion of endoscopic sinus surgery as part of the surgery.

CONCLUSION

Functional nasal surgery is a viable option to improve headache symptoms in appropriately selected patients.