Innervation of the nasal septum and lateral wall

As I have already mentioned in past blog postings I ended up with severe chronic neuropathic pain after my failed nose revision surgery in 2005 .  What's interesting is that most rhinoplasty surgeons don't educate us lay people (patients) about the risk and complications that can arise from nerve injury during rhinoplasty. In fact not only are some rhinoplasty surgeons "apparently" at a loss about my complication, one reconstructive rhinoplasty surgeon mentioned to me during the consult that there are no nerves in area of where my pain is, which happens to be the lower third of my nose ( tip lobe area including columella). Really? Well a very quick search & scant amount of reading on the internet can easily debunk that tale. However if my memory serves me right he was the first one to suggest my nerve pain may be due to Traumatic Neuroma *1. Perhaps he meant there are no main nerve branches in the tip region where my pain seems to originate from. Anyway lets now turn our attention to the nerves within the human nose.

The upper most yellow region is: Olfactory bulb, & nerves

Surgical Anatomy of the nose by Natalie P Steele and J Regan Thomas (Ch.1 Rhinology and Facial Plastic Surgery Fred J Strucker & assoc. ) 

Nerve supply to the nose is externally derived from branches of the trigeminal nerve. The skin of the nose superiorly at the radix and rhinion is supplied from branches of the supratrochlear termination of the ophthalmic nerve. The anterior ethmoidal nerve, another branch of the ophthalmic, may traverse the dorsum of the nose to supply the tip [12]. In endonasal or in open rhinoplasty, this nerve bundle may be damaged by over-aggressive endonasal incisions violating the fibromuscular layer, or elevation of the S-STE (skin-soft tissue envelope) in the wrong plane, resulting in a numb nasal tip. The infraorbital nerve may also contribute branches to the lateral nasal walls, columella, and vestibule. Knowledge of this external nerve supply is necessary to perform adequate nerve blocks for closed reductions, or for rhinoplasty under local anesthesia with sedation. Intranasal anesthesia is also a prerequisite for these procedures. This may be performed with intranasal cocaine pledgets or other strategically placed topical anesthetics. Perhaps the most important target is the sphenopalatine ganglion located in the posterior portion of the nose just posterior to the middle turbinate. Internal branches of the anterior ethmoid must also be anesthetized in the superior portion of the nose to complete a total nasal block.  

 CUTANEOUS INNERVATION
Nasal skin is innervated by the infratrochlear and external nasal branches of the nasociliary nerve, and by the nasal branch of the infraorbital nerve.

http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-0-443-06684-9..50040-8--cesec41&isbn=978-0-443-06684-9

 Olfactory Nerve (N I)    
The olfactory nerve is a special sensory cranial nerve that is responsible for the sense of smell. The receptors of these neurons are found in the olfactory epithelium and the axons pass through the cribriform plate of the ethmoid bone. These neurons synapse within the olfactory bulb which lies directly above the cribriform plate.
http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%205/cranial_nerves%20Spring%202007%20with%20figures.htm

Interesting Observation To Note.  
I have been corresponding with someone who also developed nerve related pain and discomfort after revision rhinoplasty a few years ago.  The person also had the open approach technique repeated along same previous surgical incision, as was done with my nose.  This raises suspicion as to whether repeating the open approach technique along same scarred incision increases chances of developing neuropathic pain or neuroma's due to nerve trauma along skin tissue. Another possibility for explaining nerve pain or neuroma's is large removal of scar tissue along the columella /tip region resulting in a lot of new scar tissue development during healing period which may entrap nerve tissue. The open approach has become very popularized to the point that very few rhinoplasty surgeons are performing the more complicated but less invasive closed approach technique which has it's advantages as well as some disadvantages. So with more rhinoplasty surgeons performing primary and revision rhinoplasty with the open approach we may see a rise in unexpected complications due to trauma such as nerve trauma.

*1 Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. Synonyms include scar neuroma, amputation neuroma, or pseudoneuroma.


http://books.google.ca/books?id=EccLuc0mLWoC&pg=PA5&lpg=PA5&dq=Surgical+anatomy+of+the+nose+natalie+steele&source=bl&ots=qsrQv7eKHq&sig=PlVBbsS-63jA12sYza2Cotlieho&hl=en&sa=X&ei=AhpMU4CnD6ThyQGu3YDQAQ&ved=0CEAQ6AEwAw#v=onepage&q=Surgical%20anatomy%20of%20the%20nose%20natalie%20steele&f=false

http://surgpathcriteria.stanford.edu/peripheral-nerve/traumatic-neuroma/

http://www.wisegeek.com/what-is-traumatic-neuroma.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052669/#__sec2title
https://www.youtube.com/watch?v=UGj7d1aNhsE

http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=12&cad=rja&uact=8&ved=0CGQQFjAL&url=http%3A%2F%2Fwww.springer.com%2Fcda%2Fcontent%2Fdocument%2Fcda_downloaddocument%2F9783642280528-c1.pdf%3FSGWID%3D0-0-45-1391308-p174286862&ei=g3dNU4vIIeKMyQG7-4GoDA&usg=AFQjCNHrkjIP-o8nuK0VzRQbtbt-Id63YQ&sig2=Qp43v_yLeNqIssDJhzdCAA&bvm=bv.64764171,d.aWc

Neuropathy caused by Nose Surgery. It does happen!

Can a permanent neuropathic condition occur as a result of nose surgery?

Answer: YES.

After my second major revision nose surgery by a young inexperienced surgeon in Toronto, Ontario, i developed within 6 months time severe neuropathic pain all around the tip lobe and, columella regions. The pain was so excruciating it felt like someone was taking a scalpel to my nose and slashing it. Without proper medication the pain continues to intensify feeling like a ball of  intense fireworks going off all around the tip area. Tingling leading to burning sensation would precede or accompany the severe intense pain. Another phenomena in conjunction with this pain, is hyperesthesia and allodynia.  This means the pain could be triggered further, by light sensation to the nose by touch, blowing fan, cold temperature, rain, etc.. I finally realized normal pain medication doesn't take away the pain. The only thing that helped control the pain, was anti-convulsant pills such as neurontin (gabapentin) however even though that helped somewhat, my neurologist recommended Lyrica (Pregabalin). That worked far better then gabapentin and you don't have to take as many pills. It however does have side effects one being lack of concentration and making you lethargic.

So what may of caused this? The likely explanation in my opinion according to the operative report would be the combination of or the single result of performing one of the following: excessive removal of residual scar tissue around the tip which can contain nerve tissue, and/or injuring a nerve while dissecting along the floor of the septum in order to resect a small portion of the maxillary crest. Other factors may of been use of dull scalpel, re-opening incision over previous open surgery incision along columella, improper elevation of the S-STE and/or nerve impingement or division during closing of S-STE.  My reason for mentioning this is so you are aware of this as a future patient, and that surgeons should be aware of this as well, and will hopefully make future patients aware of this as a possible side effect from the surgery, even though its remote. In fact I am not aware of anyone else with this condition, however i have read forums where a couple people mentioned they experienced nerve pain after surgery, but they never mentioned they required to be medicated with special medications like i take, or that they have a permanent condition.  One very plausible explanation for my pain according to one reconstruction rhinoplasty surgeon  is that I developed Traumatic Neuroma as a result of the surgery.

What have I done for my neuropathic pain, besides taking medication?
I first had to do a lot of research. I discovered a site which i have linked on this blog, endthepain.org which is a great site about facial neuropathic pain.  The section about Trigeminal nerve pain explains how this pain works. It's atypical however in my case, i have pain on both sides of my nose. I've had CT Scan to rule out Trigeminal Condition caused by pressure on a nerve in the brain.  I have had temporary nerve blocks, at a pain clinic, i almost had radio pulsed frequency-sphenopalatine block done, but after the pain specialist  after many appointments told me that the freezing injection could cause permanent loss of sight, i backed down from going ahead with that procedure. In fact the pain clinic in my city never performed radio pulse frequency until i mentioned it to them that it has been used as a treatment elsewhere for facial neuropathic pain. I have had botox injection in my tip area's, cortisteroid Kenalog, and inside my nose a sphenopalatine and ethmoid freezing block. I've tried cold lidocaine ointment and gabapentin cream and hot cayenne ointment cream. None had worked. The injections may of worked temporarily, but even that was inconclusive.

http://www.mcvitamins.com/neuropathy.htm

http://www.painclinic.org/nervepain-posttraumaticneuropathy.htm