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.     

A new look on septoplasties: an anatomo-clinical study and surgical procedures of the 4 main septoplasties

The aim of a nasal septum surgery is functional and aesthetic aims. With a semiologic study the authors analyse four kinds of septoplasties which allows to correct the main septal deviations: erndoscopic septoplasty for posterior nasal obstruction, Cottle's septoplasty for septum's luxation and deviation on the premaxilla area, septoplasty with spreader grafts for dorsum cartilage deviations, extracorporeal septoplasty with a new septum cartilage frame for the complex deviations. The authors emphasize on the help given by videoendoscopy during the surgical procedures.     

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.

     

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.     

A novel wedge technique to correct the curved deviation of the cartilaginous nasal septum

ObjectiveTo introduce a novel wedge technique in endonasal septoplasty to correct the curved deviation of the cartilaginous septum and describe the surgical procedure and results.MethodsA retrospective analysis was performed on 17 patients who had septoplasty using the wedge technique to correct the curved deviation of their cartilaginous septum. A 2–2.5-cm-long wedge made of either septal cartilage or ethmoid/vomer bone was inserted through an incision located 1.5–2 cm caudal to the bony–cartilaginous junction near the dorsum. Materials used for the wedge, objective evaluation of the surgical results, subjective symptom improvement and surgical complications were investigated.ResultsThe degree of deviation was moderate to severe in all patients. Bony septum was used as the wedge material in 9 patients and septal cartilage in 8 patients. Among 17 patients, 15 had a completely straight septum while 2 had a minimal curvature remaining. Subjective symptoms of nasal obstruction evaluated by the Visual Analog Scale score and Nasal Obstructive Symptom Evaluation scale improved in all patients. In acoustic rhinometry, minimal cross-sectional area and nasal volume change showed some improvement without statistical significance. There were no major complications including saddle nose and revision surgery.ConclusionOur novel wedge technique can be an effective and safe technique to straighten the curved deviations of the cartilaginous septum in selected patients.     

From Killian's submucous septum resection and Cottle's septoplasty to modern plastic septum correction and functional septo-rhinoplasty

Killian's submucous resection of the septum and Cottle's septoplasty are still described in textbooks and journals as alternative methods of treatment for septal deformities. It is the aim of this paper to show that Killian's submucous septal resection and Cottle's "maxilla-premaxilla" approach are only mile stones on the road to the modern plastic surgery of the septum. It is recommended that the names of Killian and Cottle should be dropped, and it would be better to use the terms septoplasty or plastic surgery of the septum, if deformities of the septum should be treated. These techniques also changed the methods of rhinoplasty and lead to functional septorhinoplasty.     

External septal reconstruction with the use of polydioxanone foil: our experience

We present our experience and results after using polydioxanone (PDS) foil in septal reconstruction. In a period of 2 years, 12 patients who were admitted in our department with severe septal deviation and breathing problems underwent septoplasty under general anaesthesia. The nasal septum was approached via an external approach. In all patients, after resecting and exposing the septum, the removable piece after being divided into straight pieces, was sutured onto an appropriate sized PDS foil and reimplanted together between the mucoperichondrium flaps. Sutures were placed to fixate the “new septum” to the nasal dorsum and to the anterior nasal spine. The immediate postoperative course was unremarkable and in a follow-up appointment 6 months and 1 year postoperatively, one complication occurred, with septum subluxation noted in one patient. Use of PDS foil in septal reconstruction is an important surgical option for the correction of the markedly deviated nasal septum. Fixation of the straightened and replanted septum at the nasal dorsal septum border with the upper lateral cartilages and at the nasal spine is essential.     

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.     

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.     

An approach to the nasal septum in children

Surgery of the nasal septum has long been discouraged in the pediatric population. Concerns about growth and development of the nose have led surgeons to adopt an extremely cautious attitude toward the correction of nasal septal deformities in childhood. More recently, studies have shown that with proper preservation of septal cartilage, surgery can be safely undertaken in this area. Frequently, however, exposure to the nasal septum is limited in small children due to the size of the nasal vestibule. Sublabial septoplasty has been safely carried out now in ten patients ranging in age from 4 to 9 years. This approach allows for complete access to the nasal septum while avoiding any external cosmetic deformity. The nasal septum has been preserved in all cases through morsalization and repositioning. Growth and development of the nose has been followed for up to 60 months without evidence of deformity or alteration. Sublabial septoplasty would, therefore, appear to be a safe and cosmetically acceptable approach to the correction of severe nasal septal deformities of childhood.     

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.     

Regeneration of septal cartilage in children after septoplasty. A histological study]

In eight boys aged 6.3 to 11.7 years a septoplasty had been performed according to the technique of either Cottle or Goldman. Because of new nasal obstruction 1.2 to 3.9 years later a second septoplasty was carried out. In this operation, little pieces of cartilage were excised from the formerly resected base, middle, and columellaborder of the septum for histological examination. In all pieces a regeneration of the septal cartilage by appositional and interstitial growth could be found: in a smaller amount at the resected borders of the septal base, in a larger amount at the corrected borders of the septum in the columella and in the septal middle. These histological findings of a regenerative potential of surgically traumatized septal cartilage in children by conservative septoplasty can be compared with the experiences in the growing septum of rodents.     

Long term evaluation of "push down" procedures.

The "push-down" technique for hump removal, or hump elimination, is just one maneuver of a number of surgical steps to obtain a more functionable and esthetic appearing nose. The maxilla-premaxilla Cottle approach to extensive nasal septum surgery is used, using techniques of his to modify the nasal dorsum. The "push-down" procedure usually eliminates the bony hump. The cartilaginous hump, (the upper lateral cartilage area) remains intact, and produces little trauma to the subcutaneous tissue, the mucous membranes, the periosteum, the perichondrium, and preserves the nerves and blood supply of the area. The amount of "push-down" that can be done depends on the nasal septum, which is the key to the surgical procedure. One must know how to handle part or all of the septum; its reconstruction with the patient's own bone and cartilage, so that saddling and deformity of the external pyramid and lobule may not occur later. In the repair of the roof, all anatomic relationships should be restored. The upper lateral area should be spared, however, if modified, very conservatively done and with little or no shortening. If there is partial removal of the hump, there should also be reparation of the nasal dorsum with crushed septal cartilage. Further "push-down" depends upon the width of the nose, the location and number of lateral osteotomies and intra-septal osteotomies, incomplete or complete separation of the upper lateral cartilage, done chiefly through the intra-septum space; thus, the nose becomes narrower, smaller, and the roof remains an unimpaired insulating organ playing its important physiological role. Secondary nasal revisions were minor in nature and were usually performed as outpatient procedures. The hump removal concept of total excision should be changed to "push-down" elimination of the nasal bones with total preservation of the dorsum.     

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.     

An original technique of determination of the form and fixation of septal stents

The authors consider the problems of fixation of the operated nasal septum, show shortcomings of present-day oval septal stents and technique of stent fixation, for the first time describe vector CT-anatomy of the zone of surgical intervention on the nasal septum basing on 67 computer reformations of the nasal septum and lateral nasal wall, propose optimal shape of the intranasal stent and a reliable technique of septal stent fixation to the nasal septum. The analysis of stenting of the nasal septum in 42 patients after septoplasty has shown that an original stent and a method of its fixation completely meet the requirements for septal stents.     

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.     

鼻中隔偏曲矫正术后贯穿连续缝合技术的应用与效果分析

目的　评价鼻腔填塞法和鼻中隔贯穿连续缝合技术在鼻中隔偏曲矫正术后应用的疗效及效果分析。方法  选取行鼻中隔偏曲矫正术患者158例,随机分成2组。填塞组：术后以高分子止血海绵填塞鼻腔;缝合组：术后以可吸收缝线立即行贯穿连续缝合鼻中隔黏膜。术后对患者主观不适感以视觉模拟评分法（visual analogue scale,VAS）进行评分,观察术后鼻腔黏膜水肿程度和鼻中隔血肿、粘连、术后治愈率等临床指标。结果　术后48 h内两组患者在鼻部疼痛、头部疼痛、溢泪、耳鸣/耳闷、睡眠困难、吞咽困难 6个方面的VAS评分均值比较,差异均有统计学意义。两组在术后出血量、鼻中隔血肿、鼻腔粘连、穿孔、感染等方面比较差异无统计学意义。结论　鼻中隔偏曲矫正术后缝合法较填塞法能减轻患者痛苦,不增加术后并发症的发生机率。     

鼻中隔摇门式成型术65例分析

目的探讨鼻中隔摇门式成型术的特点及方法。方法通过对65例鼻中隔摇门式成型术病人临床资料、手术方法、术后回访等进行回顾性分析。结果65例鼻中隔摇门式成型术术后1~5年回访示鼻阈的原形、韧性、硬度可,无再发脱位,中隔居中、无穿孔、无扇动。结论鼻中隔摇门式成型术对中隔高位偏曲和/或伴脱位、中隔偏曲、畸形有较好疗效,值得推广应用。     

Columelloplasty: a new suture technique to correct caudal septal cartilage dislocation

Deviation of the nasal septum is a common finding in patients with nasal obstruction and, when such deviation is severe, a septoplasty or submucous resection with or without turbinate reduction is commonly recommended for the relief of the patient's symptoms. In cases where there is anterior subluxation of the septum, the caudal margin frequently presents on one or either side of the midline at the external nares. We report a simple suture technique which, when subluxation is not severe, will correct this caudal displacement. The technique can either be used as an adjunct to conventional septoplasty or it can be undertaken as an isolated procedure in patients having routine rhinoplasty.     

A new “J septoplasty” technique for correction of mild caudal septal deviation

ObjectiveA major drawback of the Killian incision is its inability to access the caudal septum and correct caudal septal deviation. Open and hemitransfixion septorhinoplasty are considered necessary in such cases. We developed a new septoplasty method that can be successfully applied in patients with mild caudal septal deviation. In this study, we evaluated the outcome of this technique.MethodsWe prospectively collected data of 16 patients with mild caudal septal deviation who underwent endoscopic septoplasty between November 2015 and October 2017. A modified Killian incision was made on the concave side of the septum. The central part of the cartilage was preserved, and excess cartilage was resected; the central part of the cartilage was sutured to the caudal cartilage.ResultsPostoperatively, the ratio of the area of the convex side to that of the concave side in the anterior portion of the nasal cavity was significantly improved, as revealed on CT analysis (p < 0.001). Nasal obstruction was significantly reduced or eliminated in all patients (p < 0.001).ConclusionThe J septoplasty method for the correction of mild caudal septal deviation is easy to perform through a modified Killian incision, and seems to be useful in selected cases.