Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience
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RHINOLOGY
Nasal reconstructive surgery for vasculitis affecting the nose: our two‑centre international experience Samit N. Unadkat1,2 · Alfonso Luca Pendolino1,3 · Ivor Kwame1 · Andrew Swift4 · Charles Pusey5 · Andres Gantous6 · Peter J. Andrews1,3 Received: 9 May 2020 / Accepted: 28 June 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Purpose To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach. Methods A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisoleassociated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients’ signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described. Results Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mildto-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques. Conclusions The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results. Keywords Granulomatosis with polyangiitis · Vasculitis · Cocaine · Antibodies, Antineutrophil Cytoplasmic · Nasal septal perforation · Reconstructive surgical procedures
Introduction
Accepted for both an oral and poster presentation at the British Society of Facial Plastic Surgery (BSFPS), Glasgow, 2020 * Samit N. Unadkat [email protected] 1
Royal National ENT and Eastman Dental Hospitals, 47‑49 Huntley Street, London WC1E 6DG, UK
2
Charing Cross Hospital, London, UK
3
Ear Institute, UCL, London, UK
4
Aintree University Hospital NHS Foundation Trust, Liverpool, UK
5
Hammersmith Hospital, London, UK
6
University of Toronto, Toronto, ON, Canada
Vasculitis is a rare autoimmune condition that features inflammatory infiltrates around blood vessels, typically with resulting necrosis. It has a slight female-to-male preponderance and it has an incidence of 10–20 per million per year in populations of Northern European extraction. Conditions most commonly associated with the nose tend to involve small-to-medium-sized vessels and are often associated with an anti-neutrophil cytoplasm antibody (ANCA
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