Neonatal septoplasty: case report and review of the literature

Treatment of nasal septal deformity in childhood has received growing acceptance in recent years. Traditionally, concern about the role of the septum in the overall growth of the midface has led otolaryngologists to take a very cautious approach to correction of septal deformities in children. However, a great deal of evidence now suggests that severe traumatic septal deviation can and should be corrected early in childhood to prevent future nasal and systemic complications. Closed manipulation of the septum in the first 1–2 days of an infant's life has been performed by many otolaryngologists with good results. The use of this technique, however, is usually limited to those subluxations of anterior cartilage which are diagnosed immediately or very shortly after birth. We present a case of severe traumatic nasal deformity presenting with obstructive asleep and awake apnea and cyanosis at the age of 8 days. The child underwent limited septoplasty using endoscopic techniques at age 14 days with resolution of both the apneic and cyanotic episodes immediately post-operatively. This unusual presentation and the literature surrounding infant nasal/septal surgery are discussed.     

Extracorporeal septoplasty-how we do it at marienhospital stuttgart germany

Septoplasty is one of the most common surgery of ENT but even today the difficult septum still presents a great surgical problem. A severe septum deformity is usually due to an accident quite often in childhood. It is also seen in patients with malformation such as cleft lip and cleft palate deformity. It affects not only the nasal function, but also the aesthetic part of the nose. Severe septal deformities can not be corrected properly by the standard septoplasty techniques. Therefore in such cases an extracorporeal septoplasty is recommended. In this technique the whole septum is taken out, the bony and cartilaginous septum in one piece if possible, a new septal plate is reconstructed by different surgical techniques, followed by replantation and reconstruction of the cartilagenous dorsum. The first author kept on improving the safe septal fixation, rebuilding of cartilagenous dorsum and overall the extracorporeal septoplasty technique over the period of time and this technique with all its refinement can be recommended to all the surgeons dealing with this challenging noses.     

Septumkorrektur in der Septorhinoplastik

In general septoplasty precedes all other procedures in rhinoplasty as a straight, stable septum dictates the aesthetic and functional outcome. The patient??s history and expectations, correct preoperative analysis and the surgeon??s skills determine the approach in septum correction. As a rule of thumb, slight deviations, e.g. single vomer spurs, maxillary crests, the septal tilt and simple C and S-shaped deformities can be managed endonasally using a hemitransfixion incision and procedures such as the swinging door technique, scoring, batten grafts or caudal septal replacement grafts. In contrast, for severe S-shaped and wave-like deviations, cleft nose deformities, the multiple fractured septum as well as for most revision cases, the open approach with complete septal reconstruction has been found to be the method of choice. After initial general remarks on the basic procedures, the present article focuses on current concepts of septum correction which have to be adapted to the individual pathology.     

鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正治疗外伤性歪鼻畸形的临床分析

目的对鼻内镜下自体软骨（鼻中隔软骨、耳软骨和肋软骨）鼻整形同期行鼻中隔偏曲矫正治疗外伤性歪鼻畸形的临床分析。方法收集2017~2018年20 例陈旧外伤性歪鼻畸形患者的临床资料，所有患者均行全麻下鼻小柱倒“V”型切口暴露松解并切除偏曲的鼻中隔软骨及骨质，针对不同患者设计使用不同软骨（鼻中隔软骨、耳软骨和肋软骨）矫正鼻中隔骨性或软骨性支架，对鼻尖、鼻背及外鼻重新塑形。结果随访3~12个月，行鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正术的患者鼻外形及通气均有明显改善，手术效果更好，无鼻腔粘连、鼻中隔血肿及穿孔。结论鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正治疗外伤性歪鼻畸形同期解决了鼻部畸形和鼻通气功能，实现了美容和功能的统一，同时减少了手术治疗的次数和费用，可行性高。     

Excision and replacement of nasal septum in aesthetic and functional nose surgery: setting criteria and establishing indications.

Despite the technical details of the excision and replacement of the nasal septum both in aesthetic and functional nasal surgery have been extensively reviewed, in the opinion of the authors a clear and precise definition of the indications of this technique is still lacking. A simplified classification of the nasal septum deformities, based on the site and the direction of the fracture or bending axis, is proposed to establish reproducible guidelines to nasal septum surgery. On the basis of this classification the post-operative results of 227 patients affected by obstructive nasal septum deviation were evaluated. The surgical treatment consisted of conservative septoplasty in 173 cases, while in 54 cases excision and replacement of the nasal septum were performed. A conservative tension release septoplasty was performed for horizontal fracture or angulation of the septum. The more radical excision/replacement surgical approach was preferred when a vertical angulation or bending axis was observed (vertical = normal to the maxillary ridge). Twenty persisting septal deviations were found at the one year post-operative follow-up. Nineteen of these were the outcome of 173 conservative septoplasty, while only one case with unsatisfactory results was the outcome of 54 excision/replacement procedures. Seventeen out of 19 cases originally classified as horizontal deformity who presented at follow up with persisting septum deviation were reclassified as vertical. The reason for surgical failure must be probably identified in a preoperatory classification mistake where vertical deformities were erroneously evaluated horizontal and operated accordingly. The authors suggest excision/replacement of the nasal septum whenever its fracture or major bending axis is vertical.     

The septum in rhinoplasty

Recognition and correction of septal abnormalities in rhinoplastic surgery has been a constant evolution aided by the development of an in depth anatomic understanding of the nose and the refinement of techniques based on the pertinent anatomy. Whether the deformity presents a functional, aesthetic, or combined problem, the authors prefer a single stage technique that separates the structural components of the nose, isolating the deformities present, and then reconstructing the components to effect a desirable result in terms of airway and appearance. Although no two nasal surgeries are identical, there are characteristic deformities that are noted to be generally more problematic. We briefly review normal septal anatomy as it pertains to the septorhinoplasty operation and then discuss our approach to specific septal variations that we have found to have a significant impact with regard to achieving satisfactory functional and aesthetic results.     

Management of naso-septal deformity in childhood: Long-term results

Objective

The classical teaching advocates a conservative approach for children presenting with various naso-septal deformities. It may not be appropriate especially when it causes nasal obstruction to the growing child. This study has two main purposes: to contribute in identifying the correct selection criteria for surgical management of pediatric patients and in selecting the most appropriate surgical technique.

Material and method

We reviewed a series of 46 cases of post-traumatic septal and naso-septal deformity not managed promptly or with recurrence of nasal deviation, following bones fracture correction alone. The mean follow-up was 10 years.

Results

Patients with naso-septal deformity managed only by septoplasty had accentuation of nasal pyramid deformity; those treated by septorhinoplasty showed a good aesthetic and functional result after long-term follow-up.

Conclusion

Our series results demonstrated that the best results were obtained when we correct all evident alterations of nasal septum and pyramid at a single stage. Unsuccessful results seen in our first group suggest that immediate correction of septum alone with delayed management of nasal pyramid deformity leads to a poorer outcome.     

Acoustic rhinometry: evaluation of the nasal cavity with septal deviations, before and after septoplasty

We introduce acoustic rhinometry as a new, objective method to assess the geometry of the nasal cavity. The cross-sectional area of the nasal cavity as a function of distance from the nostrils was obtained. A group of 21 patients with septal deformities was examined with acoustic rhinometry preoperatively and postoperatively. These values were compared with those of 21 normal control subjects. The minimal cross-sectional area (MCA) is located in the anterior part of the nose, and it shifts anteriorly under the effect of decongestion. The preoperative value of MCA is related to the location and severity of the anterior septal deformity. Postoperative smaller MCA found in the opposite side of that narrowed by a severe anterior septal deformity may be explained by the impact of septoplasty without reduction of a hypertrophic turbinate. A highly significant relation between MCA and the subjective feeling of nasal patency, before and after surgery, suggests that MCA is a valuable parameter to express nasal patency. Correction of posterior septal deformities is found to increase significantly the cross-sectional area posteriorly. The effect of decongestion in the postoperative values, however, suggests that the mucosa contributes even more to the cross-sectional area of the posterior part of the nose. Acoustic rhinometry seems very suitable for evaluation of the nasal cavity in cases where septoplasty and turbinoplasty is considered, as well as for the postoperative evaluation.     

A review of practical guidelines for correction of the deviated, asymmetric nose

Repair of the twisted nose presents a challenge, as often functional problems as well as aesthetic deformities must be addressed. Traditional correction of the deviated nose involves septal correction, separation of both upper lateral cartilages from the septum and bony pyramid manipulation after osteotomies. Nowadays autogenous cartilage grafts are being used for repositioning, reinforcement, recontouring and reconstruction of virtually every component of the nasal skeleton. These restructuring techniques follow the modern principles mentioned above and may well be applied to the deviated asymmetric nose. The grafting manoeuvres increase the stability of the realigned cartilaginous nasal framework, including the nasal septum, but may also be used for camouflaging purposes. The large number of possible individual anatomic variations including facial asymmetry does call for a systematic approach based on succinct individualised analysis.     

鼻中隔软骨移植物在外伤后鼻背畸形修复中的应用

目的 探讨鼻中隔软骨移植物在外伤后鼻背畸形修复中的应用。 方法 自2014年1月至2016年12月为43例鼻外伤后鼻背畸形患者实施了鼻中隔软骨移植物的植入修复。外伤后鼻部骨性及软骨性鼻锥塌陷、变宽呈鞍型。根据鼻背凹陷的程度,选择没有破碎的鼻中隔软骨,按照鼻背凹陷的形态,修剪缝合成型,经由鼻翼缘切口置入软骨移植物矫正外伤后鼻背畸形塌陷。 结果 随访1~3年,9例患者因鼻部外观欠佳,实施二次鼻畸形修复手术,取得较好的鼻背外观。 结论 鼻中隔软骨移植物在外伤后鼻背畸形手术矫正中具有非常重要的应用价值,可对骨性和软骨性鼻锥的凹陷起到填充作用,使骨性和软骨性鼻锥保持连续性。但术后也存在软骨局部吸收变形、外观轮廓欠佳等不足,需通过填充材料的改进来进一步提高手术效果。     

Endoscopic septoplasty

Endoscopic septoplasty is a minimally invasive technique that helps us to correct defornity of septum under excellent visualization. Lanza et al & Stammberger initially described the application of endoscopic technique for the correction of septal deformity in 1991. A retrospective study was carried out of all the cases that underwent endoscopic septoplasty at Dr. Shroff’s Charity Eye hospital from March 1998 to March 2000. 78 consecutive septoplasty patients were identified in two years. Out of these 48 septoplasties (52%) were performed with endoscopic technique. A large percentage of cases 48(41%) were those where septoplasty was performed in conjunction with endoscopic dacro cysto rhinostomy. In 8 cases (16%) it was performed alone as a primary procedure, 4 deviations were broadly based deflections (12%), 10 of septal deformities were spurs (20%), in 4 cases more than one type septal deformities were encountered. Thus we feel that endoscopic septoplasty is a fast developing concept & gaining popularity with increasing trend towards sinus endoscopic surgeries. Furthermore in complex deformities, better correction is possible with the help of endoscope. Since we can clearly see the posterior deviations.     

Are some septal deformities inherited? Type 6 revisited

OBJECTIVE: There has been little research into inherited septal deformities. While, Peji? carried out a study some 50 years ago, and Grymer more recently suggested that some posterior septal deformities could be inherited, both studies lack a precise definition of the types of septal deformities which were investigated. The aim of this paper is to investigate the hypothetic influence of heredity on the onset of particular types of septal deformities. The authors investigated a very particular and well defined type of septal deformity: type 6 after Mladina's classification. METHODS: The authors studied a group of 22 children among 779 children aged 7-14, selected at random, suffering from type 6 septal deformity and their 44 parents. They were examined by means of anterior rhinoscopy by two the same ENT specialists in rhinology. The control group consisted of 24 children with a straight nasal septum of the same age and sex distribution and their 48 parents. The results were compared using Fisher's exact probability test. RESULTS: In the studied group type 6 septal deformity was found in 21 out of 22 both fathers and mothers of these children. Type 6 was not found in any of 48 parents of children with no septal deformity. CONCLUSIONS: There is a high positive correlation between the appearance of type 6 septal deformities in both mothers and fathers of children with this type of deformity. The high correlation in the incidence of type 6 nasal deformity in mothers and their children and in fathers and their children suggests that this type of nasal deformity is inherited. Most authors hold that only posterior septal deformities result from inheritance factors, while anterior deformities result from environmental factors, that is, from injury to the nose and the central massif of the face. However, our study of type 6 deformities shows that certain types of anterior deformities can be inherited.     

Incidence and treatment of deviation of nasal septum in newborns

Four thousand and ninety consecutive newborns were investigated for nasal septal deviations over a two-year period in the Bnai Zion Medical Center, Haifa. An incidence of 0.93% of anterior nasal septal cartilaginous dislocation was found. No statistically significant correlation was observed between the newborns' weight and the nasal deformities. Definite correlation between the type of delivery and the nasal deformity was noted, however. The importance of early treatment during the first three days after birth is stressed. The infants were followed for a three-year period and no evidence of recurring septal deformity was noted. Birth trauma was first reported by Metzenbaum in 1929 as being a causative factor in nasal septal dislocation. Since then, it has been reported by other authors. Deviated nasal septum in the newborn is said to occur due to various intrauterine and transnatal pressures operating on the fetus. In 1963, Klaff reported 12 cases of septal dislocation in newborns and went on to describe the causative factors and methods of treatment. Gray investigated septal deformities in 2,380 infants at birth and found anterior cartilage deformity in 4%. He put forward a maxillary moulding theory of transmitted pressure during pregnancy or birth in an attempt to explain septal deformities in the newborn. Hartikainen et al. screened 4,724 newborns for congenital nasal deformities and found a 1.9% incidence of anterior septal dislocation. In this study no evidence of birth trauma as the cause of congenital nasal deformities was found and it was proposed that the majority of dislocations originated during intrauterine life. Collo reported correction of 19 birth traumatic nasal septal deviations by manual manipulation.(ABSTRACT TRUNCATED AT 250 WORDS)     

The nasal septum in relation to the development of the nasomaxillary complex: a study in identical twins

The influence of the nasal septum and respiration, evaluated by the total nasal resistance (TR) on the development of the nasomaxillary complex, was studied in 42 identical twins. An understanding of this influence is important for a determination of whether surgery involving the nose should be performed in children. Comparison within and between twins with different septal deformities indicated that the cartilaginous nasal septum influences the development of the nose and the anteroposterior dimensions of the maxilla. Anterior septal deformities resulted in underdeveloped cartilaginous noses and a shorter anteroposterior dimension for the maxilla. No relation was found with regard to posterior septal deformities, which may be considered as part of the development of the midface. Vertical dimensions of the face were related to TR. Increased values of TR were significantly related to a shorter maxillary height. This may not express a causal relationship but rather genetically determined shorter facial dimensions.     

A new technique during septoplasty to prevent saddle nose

• ? During septoplasty, especially in patients with severe deviation of the nasal septum, there is the risk of septal instability, which may result in a saddle nose deformity. Therefore, prevention of this unwanted outcome is very important and removes surgeon’s anxieties.
• ? This article describes a simple technique during septoplasty to prevent the development of this serious complication.
• ? In this surgical technique, the dislocated nasal septum is lifted and stabilised with a temporary traction suture. This traction suture holds the mobile septal cartilage in the proper position to restore and support the nasal dorsum and provides it with a normal contour.
• ? The advantages of this technique are that it is (i) easy to perform, (ii) not time‐consuming, (iii) is less traumatic compared to other methods, (iv) is comfortable for the patient and (v) provides long‐term stability.

     

鼻外进路治疗鼻中隔高位及后段偏曲

目的探索安全有效矫正鼻中隔高位及后段偏曲的手术方法。方法采用鼻外进路,保留鼻中隔软骨,矫正鼻中隔偏曲。结果1992年1月～2002年1月共治疗鼻中隔高位偏曲55例,术后随访6月～1年,鼻塞症状缓解42例,头痛症状缓解27例,嗅觉恢复12例;3例鞍鼻、16例歪鼻畸形者矫正满意,5例歪鼻半年后复发。该方法具有视野大,操作方便,不会引起鼻梁下塌等优点,可安全、彻底地矫正鼻中隔高位及后段偏曲。结论鼻外进路治疗鼻中隔高位及后段偏曲比传统的鼻中隔矫正术更安全有效,并可同时矫正外鼻畸形。     

Septoplasty by disarticulation

The difficulty of correcting nasal septum deformities using the classical Killian or Cottle techniques or derivatives has led in recent years to new suggestions such as extracorporeal septoplasty or various apposition grafts to counteract refractory deformity of the quadrangular cartilage. Naturally occurring septal deformities result from conflicts in growth between the quadrangular cartilage, perpendicular ethmoidal plate and vomer, which each have their own different evo-devo origin. Septoplasty by disarticulation consistently restores a level septum by completely resolving the growth conflicts. Conserving the quadrangular cartilage is essential for the stability of the nasal pyramid on condition that 1) the lateral flare of the superior edge of both the component septolateral cartilages that suspend it at the roof of the piriform orifice and 2) the height of its anterior edge are respected. The anterior edge is always high enough (except in case of fracture or malformation to project the retrolobular nasal dorsum in proportion to the height of the alar cartilage when it is repositioned on its natural premaxillary base.     

Total septal reconstruction through decortication (external) approach in children

Severe posttraumatic deformities of the ventrocaudal and ventrocranial septum in children continue to present a serious challenge to the modern rhinosurgeon. Conservative septoplastic techniques through Cottle's approach produce an untolerably high rate of recurrence or insufficient restoration of the function of the nose. The total septal reconstruction through decortication (external) approach is proposed as a solution for this problem. After temporary elevation of the skin, the nasal septum is approached in between the lower lateral cartilages. The mucoperichondrium is elevated, and the entire septal cartilage is removed. The straight part of the cartilage from the central part is used to reconstruct the ventrocaudal and ventrocranial septum, while the deformed cartilage is straightened by crushing and positioned in the posterior septal space. The cartilage graft is precisely sutured to the upper lateral cartilages and to the fibers of the septospinal ligament. In an eight-year period, five girls and 19 boys, aged 5 to 14 years, were operated on using this technique. Satisfactory functional results were obtained without any major complications in all patients. There were neither serious alterations of the growth of the nose, nor the necessity for reoperation. Total septal reconstruction through decortication (external) approach is useful for correction of severe septal deformities in children.     

20 years' experience with extracorporal septoplasty

Even today the difficult septum presents a surgical problem. A severe septum deformity is caused mostly by an accident or is seen in patients with malformation like CLP-deformity. It is characterized by a massive deformation in all levels with a consecutive blocking of one or both airways. Such severe septal deformities cannot be corrected properly by classical septoplasty techniques. Therefore we suggest an extracorporal septoplasty, where the whole septum is taken out and by different techniques a new septal plate is reconstructed and then replanted. From 1981 to 2001 we operated 1855 patients and improved this method constantly, especially the safe septal fixation after replantation. Follow-ups showed that even in severe deformities a revision rate of only 5 % respectively 7 % was found. Therefore we conclude the extracorporal septoplasty with its refinements can also be recommended also to the less experienced rhinosurgeon.     

Nasal septal deformities in ear, nose, and throat patients: an international study

PURPOSE: The purpose of this study was to investigate the incidence and characteristics of nasal septum deformities in ear, nose, and throat (ENT) patients in various geographic regions in the world. MATERIALS AND METHODS: Anterior rhinoscopy without nasal decongestion was performed in 17 ENT centers in 14 countries. The septal deformities were classified according to the classification system proposed by Mladina. RESULTS: A total of 2589 adult ENT patients (1500 males and 1089 females) were examined. Septal deformities were found in 89.2% of subjects. Left-sided deformities were slightly more prevalent than right-sided deformities (51.6% and 48.4%, respectively). The most frequent type of deformity was type 3 (20.4%). Straight septum was found in 15.4% of females and 7.5% of males. CONCLUSIONS: Almost 90% of the subjects showed 1 of the 7 types of septal deformity. There were no statistically significant differences in the incidence of their appearance among particular geographic regions. Type 3 was the most frequent type. Straight septum was twice as frequent in females than in males.