The Journal of
Laryngology and Otology (Founded in 1887 by MORELL MACKENZIE and NORRIS WOLFENDEN)
September Septoplasty Rational surgery of the nasal septum By NIGEL EDWARDS (Bristol) Summary
THE Submucous Resection (S.M.R.) operation ascribed to Killian, still widely taught as the standard surgical treatment of obstructive septal deformities, has serious deficiencies in many common clinical situations. The reasons for this are critically discussed in the light of the surgical anatomy and physiology of the nose as a whole. The rational, conservative and versatile principle of septoplasty has evolved over half a century, until today the author considers that it should largely supersede the old S.M.R. The principles and the indications for septoplasty are discussed. The basic septoplasty procedure used by the author is described with practical details, together with all the variations and extensions possible as far as a complete septo-rhinoplasty. The importance is stressed of accurate assessment of the whole nasal problem and precise correction of all primary and secondary obstructive factors. Introduction
The earlier surgical manoeuvres used in attempts to correct obstructive septal deformities are well documented elsewhere (Huffman and Lierle, 1957; Maran, 1974); they include forcible 'dilatation' of the nose with septal fracturing and subsequent splinting (Adams, 1875; Asch, 1899), local excision of obstructive projections, and even full thickness resection of portions of the septum. 875
Nigel Edwards The advent of the 'submucous resection' (S.M.R.) therefore represented a notable surgical advance. Although the S.M.R. (or 'fenster-resektion') has long been attributed to Killian (1904, 1905), it would seem likely that surgeons in several centres developed the technique at about the same time—Ingals (1882), Krieg (1889) and Freer (1902) among others should be recognized as pioneers. On reading the clear accounts by St. Clair Thomson (1906) and Yankauer (1906) of the early S.M.R. operation, one is impressed by the fact that little has changed in the technique over 70 years. An operative procedure which has persisted virtually unaltered for so long a time must have considerable intrinsic merit, as Maran (1974) has stated, but there are few who would argue that this limited technique is capable of dealing adequately with many types of obstructive situation of the septum. As early as 1929 and 1936 Metzenbaum reported his limited repositioning technique which can be regarded as the forerunner of modern septoplasty: Peer (1937) added an improvement. In the post-war period, the work of Fomon, Becker, Goldman, Cottle and others has led to a better understanding of nasal physiology and surgical anatomy, and to the evolution of the modern septoplasty concept. In spite of this, inappropriate use of the S.M.R. procedure continues to give some unsatisfactory results, which tend to tarnish the reputation of corrective septal surgery. The following section is devoted to a critical analysis of the role and limitations of the S.M.R.—the more experienced reader may wish to pass directly to the discussion of surgical anatomy and description of septo-plastic procedures. The submucous resection operation of Killian (S.M.R.) is so familiar and well described in standard texts as to require no detailed description here. It permits the subperichondrial and subperiosteal removal of obstructively deviated quadrangular cartilage, and bone of ethmoid plate and vomer; but the borders of the 'free' or mobile portion of the septal cartilage must be preserved intact if certain serious post-surgical sequelae are to be avoided (Figs. 1 and 2). An adequate preserved free margin must be at least 6 to 8 mm. in depth along the caudal and ventro-cephalic borders. The penalties paid later by the patient (Figs. 3 and 4) if the surgeon disobeys these rules, are: (1) Upward recession of the Columella (due to inadequate resistance of the caudal strut) later followed by flattening and 'prolapse' of the nose tip in severe cases. Both events lead to renewed airway obstruction at anterior narial level. (2) Supra-tip depression or 'saddling' deformity (due to inadequate resistance of the ventro-cephalic cartilage strut). Later surgical correction of these avoidable iatrogenic deformities is difficult and often unsatisfactory, due to fibrous contracture of soft tissues and the uncertainty of free tissue grafts. Columellar recession and 876
(b) (c) (d) (e) (/) (g) (h)
(a)
FIG. I.
Nasal Septum—Components septal (quadrangular) cartilage, with attachment of upper lateral cartilage, ethmoid bone, perpendicular plate, vomer, nasal bones with fronto-nasal spine, cribriform plate of ethmoid, sphenoid and sinus, hard palate with maxillary crest, anterior nasal spine.
2.
Nasal Septum after Submucous Resection (i) ventro-cephalic cartilage strut with attached upper lateral cartilages, (ii) caudal cartilage strut, (iii) anterior nasal spine. The broken line indicates the acceptable limits of septal resection. The arrows indicate the lines of tension resisted by the septal catilage struts.
FIG.
en T
Nigel Edwards
FIG. 3. Minor Post—S.M.R. Defoimity. Mild Supratip Depression.
tip collapse is the more difficult problem, particularly if the anterior nasal spine has been removed; the type of S.M.R. attributed to Hajek (1892) and quoted by Yankauer (1906), in which the caudal septal cartilage is resected with the spine, is roundly condemned. 'Supra-tip saddling' or ventro-cephalic marginal depression is more easily disguised by insertion of subcutaneous implants of tissue grafts or foreign material, but some airway obstruction may be hard to correct. The incidence of post-S.M.R. deformity and unsatisfactory functional results tends to be underestimated (although no statistics are available), since they usually do not appear for several months after the patient has been discharged from follow-up. The legitimate applications for the S.M.R. then are the midseptal obstructive deformities where adequately wide (i.e. 6 to 8 mm.) caudal 878
Septoplasty
FIG.
4.
Major Post-S.M.R. Deformity—Supratip Depression. Columellar Recession and Prolapse of Nose Tip.
879
Nigel Edwards and ventro-cephalic struts of quadrangular cartilage can be left intact (Fig. 2). The S.M.R. technique is clearly not suitable for dealing with the following frequently-encountered obstructive or cosmetic septal deformities: (1) The Caudally-dislocated Septal Cartilage ('caudal dislocation') estimated to occur to some degree in at least 50 per cent of adult septal deformities requiring surgery. The large majority of children's septal deformities are of this type. (2) The ventro-cephalic septal cartilage border, with attached upper lateral cartilages, which is bowed away from the mid-line, or serpentine. (3) The ventro-cephalic septal cartilage strut which slopes vertically from the midline [the 'high cartilaginous deflection). Other disadvantages of the S.M.R. procedure are listed as: (a) Loss of normal septal rigidity—the 'flapping septum'—in areas of cartilage and bone resection. (b) Considerable liability to early or later septal perforation in these areas. (c) Weakening of the septum and portions of the nose supported thereby, significant in the event of further traumatic injury to the nose. (d) Technical difficulties of revision surgery where septal cartilage and bone are removed. Septoplasty is here defined as a conservative and versatile system of corrective septal surgery, soundly based on consideration of the surgical anatomy of the whole nose, and having due regard to its physiological functions. Such a system must be adaptable enough to deal with all types of septal deformity—the S.M.R. procedure has been found wanting in this respect. Before practical operative techniques are described, the surgical anatomy of the nose, and the principles underlying successful corrective septal surgery need to be discussed. Surgical anatomy of the nose The disposition of the cartilaginous and bony parts of the nasal septum are illustrated in Figure 1. They are well described in standard texts and need no further description here. The role of the septum as a supporting structure, however, has been the subject of argument over many years, and is today not always clearly understood (Huffman and Lierle, 1957; Wright, 1969). The concept of the nasal cavities being maintained by three separate nasal vaults, each with its own individual relationship to the nasal septum, was clearly stated by Fomon (1946 and 1948) and Becker (1951), and is considered valid and helpful in understanding the important supporting structures whose integrity must be 880
Septoplasty respected by the surgeon. Cadaver dissection will readily confirm these facts (Fig. 5). (i) The bony vault (Fig. 5a) is strong and rigid, consisting of the paired aasal bones and contiguous maxillary processes. The fronto-nasal spine idds an important central strengthening buttress (Clark, 1967). The inderlying nasal septum (bony perpendicular plate of ethmoid, and a >mall part of the quadrangular cartilage) plays no significant supporting •ole in the bony vault.
FIG. 5, The Three Nasal Vaults. A. Bony vault: (i) Nasal bones, (ii) maxillary process, (iii) maxillary crest and vomer, (ivi anterior nasal spine, (v) septal cartilage with upper lateral cartilages removed. B. Upper Cartilaginous Vault: (vi) upper lateral cartilage, C. Lower Cartilaginous Vault: (vii) lower lateral cartilage.
(2) The upper cartilaginous vault (Fig. 56) consists of the paired upper iteral cartilages and their intimate line of medial fusion with the whole if the ventro-cephalic border of the quadrangular septal cartilage from •eneath the nasal bones down almost to the septal angle. Variable ccessory cartilages also lie in this fibro-cartilaginous sheet which lies on . deeper plane and underlaps both the bony vault, to which it is firmly .ttached, and the lower cartilaginous vault to which it has only a loose 881
Nigel Edwards attachment. The lower free margins of the upper lateral cartilages form part of the 'nasal valve', an area of great importance in determining the aerodynamic properties of the nasal air passages (Bridger, 1970). Apart from the relatively narrow upper attachment to the underside of the nasal bones and adjacent septum, and the upper margins of the bony piriform aperture, the upper cartilaginous vault depends for its support on the integrity of the quadrangular septal cartilage. Hence the readiness and ease with which fibrous contracture in the septal flaps can produce a 'supra-tip saddle' if the remaining ventrocephalic septal cartilage strut is not strong enough to resist this tension. The septal and paired upper lateral cartilages in effect form a unit, the 'septo-lateral cartilage'. It is an embryological and morphological entity (Fomon, 1946). The 'keystone' of the arch is the midline junction of the septo-lateral cartilage with the under-surface of the nasal bones (Figs. 1 and 56). This important area may easily be damaged during hump removal and medial osteotomies in the course of a rhinoplasty. (3) The lower cartilaginous vault (Fig. 5c) consists of the paired lower lateral (or alar) cartilages, and overlaps the lower part of the upper cartilaginous vault, to which it has a loose fibrous attachment. Its virtual independence of the upper two vaults allows considerable mobility and sliding movements of the nose tip structures relative to the septum and other vaults. The lateral crura determine the shape of the nasal alae, and functional adequacy of the anterior nares to large extent, being movable by the dilator muscles. The paired domes are joined together to form the nose tip, and the medial crura are likewise closely joined in the columella. It is important to appreciate that the support of the nose tip depends directly upon the correct alignment of the paired medial crura in the columella, and not upon the septum. The caudal part of the septal cartilage, however, plays an important indirect role here, by maintaining the correct alignment of the medial crura, and resisting the upward traction forces of scar tissue (Fig. 2). The aims of corrective septal surgery need now to be defined: (1) Adequate correction of obstructive septal deformity and restoration of function. (2) Surgical correction of secondary effects of septal deformity, which themselves cause impairment of function and which are not expected to revert to normal spontaneously (a) hypertrophic middle turbinates which need physical reduction or outfracturing—an important manoeuvre since the inspiratory air-stream normally passes between middle turbinates and septum (Proetz, 1951), (b) chronically congested and hypertrophic inferior turbinates which need surgical reduction or submucosal diathermy coagulation,
Septoplasty (c) nasal polypi, (d) secondary infective sinusitis, (e) obstructively hypertrophied posterior ends of the inferior turbinates. (3) Preservation of the supportive role of the nasal septum as defined above, and prevention of the usual post-surgical deformities (columellar recession, tip prolapse, supra-tip saddle). (4) Preservation of a firm septum normally capable of withstanding future accidental nasal trauma. (5) Avoidance of a flapping septum devoid of skeletal support and liable to immediate or late perforation. (6) Correction of cosmetic deformities of the columella and of any or all of the three nasal vaults. The author considers the customary distinction and separation of functional aspects of nasal deformity ('the province of the otorhinolaryngologist') from cosmetic aspects ('the province of the plastic surgeon') to be illogical and indeed pernicious. The height of absurdity is reached when a patient with a complex nasal deformity is twice admitted to hospital for surgery in the two different departments; the end-result is often a far-from-ideal compromise. Success in septoplastic surgery demands adherence to certain basic principles which are briefly discussed. (a) adequate surgical exposure involving at least a partial, or often a complete septal transfixion through intercartilaginous incisions, (b) adequate subperichondrial/subperiosteal elevation of flaps on both sides; equally over septal cartilage (which does not require an attached pedicle with blood vessels and indeed survives equally well as a free graft), since tension stresses from fibrous contracture will be as nearly equal and opposite as possible, (c) minimal sacrifice of septal skeletal tissue and lining: trimming and repositioning rather than resection, (d) thorough exposure and surgical freeing of deformed structures from all extrinsic distorting influences, so that natural anatomical relationships are restored by elimination of tension, (e) correction of intrinsic deforming influences in cartilage according to the principles expounded, on the basis of experiment, by Hunter Fry (1966, 1967, 1968), Kenedi et al. (1963), and others. Partialthickness linear cuts on the concave side of a portion of twisted cartilage will allow uncurling of the concavity and gaping of the knife-cuts, due to release of internal tissue tensions in the cartilage. With experience, controlled and stable straightening of complex cartilaginous twists can be achieved. 883
Nigel Edwards (/) correction of deformed bone by precise trimming, or controlled fracturing back into position; it is desirable to leave periosteum attached on at least one side, (g) maintenance of restored and corrected relationships between structures wherever possible by careful internal and external splinting rather than by sutures. Attempted coercion of structures under tension, by sutures or splints, is doomed to failure, particularly with cartilage. The possibility of late recurrence of deformity due to unequal scar tension must always be borne in mind, (h) prevention of undesired overlapping of septal fragments placed edge to edge by fine absorbable mattress sutures transfixing the flaps, passing first between the fragments and on return through the anterior one, (i) careful internal splinting with continuous half-inch petroleum jellysoaked ribbon gauze is left for four days; it accurately maintains the desired tension-free structural alignments, prevents unwanted adhesions, and is easily removable, (k) elimination of infection which is a rare but serious complication —avoidance of haematoma is the best safeguard, but antibiotic cover for a week with penicillin, where appropriate, is routine, (/) use of asteroid-decongestant nasal spray four times daily ('Vasocort') which helps to reduce post-operative reactive oedema after removal of the nasal ribbon pack. Septoplasty: surgical assessment and management
It can not be too strongly emphasized that success in corrective surgery of the nasal air passages depends, firstly, on an accurate preoperative assessment of the problem, and secondly, on choice and precise execution of all the appropriate surgical manoeuvres. It is of limited value to the patient to have a perfect septal repositioning carried out, if other obstructive factors remain unrecognized and untreated.
At anterior narial level, the columella may be excessively wide and flared, or unduly recessive; or the alae may be unduly long and thin, tending to collapse on inspiration. Columellar narrowing or reshaping, or a tip correction to adjust the shape, height, width and angle of the nares may be needed. The silver wire splints of Francis have not proved generally satisfactory in cases of 'alar collapse'. Inside the nose, undue prominence of the anterior pole of the inferior turbinate often needs submucosal diathermy-coagulation, or rarely a subperiosteal resection of bone. In the middle reaches of the nose, careful attention to securing a clear air passage between middle turbinate and septum by 'dilatation' is amply repaid in results. Vomerine spurs are often of minimal significance (Proetz, 884
Septoplasty 1951), except in the pre-sphenoid region where they can cause serious obstruction and should be resected, or trimmed off by osteotome. At choanal level, bulky posterior poles of the inferior turbinates may obstruct, and act as 'ball-valves'; they should then be snared off. Lastly, any sinusitis, polyposis or adenoidal hypertrophy should be dealt with appropriately. The septal problem In the author's clinical experience, obstructive septal deformities fall naturally into three broad categories: (1) The Simple Mid-Septal Deflections—some 25 per cent of cases. There is no caudal cartilage dislocation or high septal deflection, and the S.M.R. technique deals with them adequately. They are not considered further. (2) The Simple Caudal Cartilage Dislocation—some 65 per cent of cases —with or without concomitant midseptal deformity. Septal deformities in children are typically of this type and a 'Conservative Septoplasty' involving minimal sacrifice of cartilage is indicated— in the author's view, age is no contraindication to this procedure if obstruction is severe. In adults some degree of limited midseptal resection is usually combined with the septoplasty. (3) The Complicated Caudal Cartilage dislocation—with one or more of (a) Significant distortion of the Upper Cartilaginous Vault, (b) Deformed tip, unconnected with (a), requiring formal tip correction of Lower Cartilaginous Vault, (c) Deformed bony vault. These cases require (a) Extended septoplasty (Upper Cartilaginous Vault) (b) Cartilaginous rhinoplasty (Upper and Lower Cartilaginous Vaults), (c) Septorhinoplasty (Bony with Upper and Lower Cartilaginous Vaults). (Patterson, 1966; Clark, 1967; Smithdeal, 1968). It is the specific purpose of this paper to describe the surgical techniques embodied in the 'Basic (or conservative) Septoplasty' and the 'Extended septoplasty' procedures. A working knowledge of standard rhinoplastic techniques will make the 'Cartilaginous Rhinoplasty' (embodying tip correction) and 'Septo-Rhinoplasty' (embodying osteotomies and infracture as well as tip correction) readily intelligible to the informed reader. A special variation of the 'Extended Septoplasty' is 'Septoplasty with Total Cartilage Repositioning'; it will not be mentioned further here, but will be the subject of a later publication. 885
Nigel Edwards THE BASIC OR SIMPLE SEPTOPLASTY is the common first stage to all the more extended problems, and is based on the method described by Goldman (1956). Access to the septum is obtained by a limited caudal transfixion incision, from septal angle to base of anterior nasal spine. The columellar base is loosened by blunt scissors dissection, as described by Goldman, and a through-and-through columellar mattress suture ('basal modelling suture') placed to obtain columellar symmetry. The mucoperichondrial flaps are elevated equally on both sides starting close to the anterior nasal spine, and working backwards and upwards to encompass the septal deformity. The flaps are then separated by sharp dissection from the nasal spine and vomer down to the nasal floor. The dislocated septal cartilage is trimmed and cross cut to straighten out concavities, until it is comfortably re-seated on the anterior nasal spine and vomerine groove under no tension (Fig. 6).
A. B. C. D.
FIG. 6. The Basic Septoplasty I. Typical deformity found with caudal cartilage dislocation, Mucoperichondrial flaps being elevated equally on both sides, Corrective partial-thickness cross-cutting; base trimmed, Straightened cartilage splinted to flaps by transfixing mattress sutures which also prevent antero-posterior displacement and overlapping. Cartilage foot anchored to anterior nasal spine.
Oblique-vertical fracture lines, angulated or overlapping, are frequently found; these are best re-opened by the knife, and excess cartilage trimmed off, so that the fragments fit edge to edge without tension. It is usually found convenient in practice to reconstitute the caudal portion of the 886
Septoplasty septal cartilage as two thin mobile independent parallel struts, attached only by a thin pedicle above (Fig. 7)—the pedicle is retained for orientation and not for the sake of its blood supply (Goldman, 1956). One single strut, or three thinner ones, may be fashioned according to local circumstances, but one should aim to retain a total depth of septal cartilage of 10 mm. or more as a caudal buttress for the columella. Behind this buttress a limited midseptal resection may safely be carried out; vomerine spurs may be trimmed off by osteotome. The 'foot' of the caudalmost strut is stitched to the soft tissue left attached to the anterior nasal spine, and there acts as a 'front marker' (Fig. 7).
FIG. 7. The Basic Septoplasty II. (a) Caudal cartilage strut anchored on anterior nasal spine by suture, (6) supporting strut which may be duplicated—note the transfixing mattress sutures which prevent overlapping of struts and splint struts to flaps, (r) 'midseptum' which may be repositioned by trimming and conservative coriection or resected.
The septal repair is commenced by a vertical row of two transfixion mattress sutures of 4 • 0 plain catgut (used throughout) applied by a fine curved Reverdin needle (Fig. 7). The outgoing strand pierces both flaps just behind the back edge of the posterior strut, between it and remaining septal cartilage, returning to pierce the cartilage strut itself. Thus backward shifting of the strut and overlapping is prevented. Similarly a further row of mattress sutures fixes the caudal strut in relation to the posterior strut. The caudal transfixion incision is repaired by mattress 887
Nigel Edwards sutures on a straight cutting needle which behind picks up the edge of the two flaps of the caudal cartilage, and in front picks up the skin edges of the membranous septum attached to the columella. The operation closes with insertion of a continuous internal splint of half-inch ribbon gauze soaked in petroleum jelly, loosely filling both nasal cavities from floor to roof and holding the repaired septum securely in the middle line. It is particularly important that this ribbon splint should be applied accurately between the outfractured middle turbinate and the septum. The splint is removed without trouble after four days, and spraying of Vasocort commenced four times daily, alternatively, silastic sheet splints stitched to the septum may be preferred (Gilchrist, 1974), especially in children, and left in place for several weeks. Antibiotic cover for one week is routine. Rapid uneventful healing is the rule; septal perforation is virtually unknown. THE EXTENDED SEPTOPLASTY (Fig. 8)
This implies extension of the Basic Septoplasty stage described above to include exposure and manipulation of the Upper Cartilaginous Vault,
A. B. C. D.
FIG. 8. The Extended Septoplasty. Upper caitilaginous vault deformity with dorsum deflected to the left, After elevation of dorsal skin, full transfixion, and subperichondrial elevation of septal flaps—upper lateral cartilages are cleanly severed from septal attachment; corrective cross-cuts are shown, Septal cartilage has regained midline position, Upper lateral cartilages reattached to septum by sutuies.
Septoplasty necessitating intercartilaginous incisions, undercutting of the dorsal nasal skin and a full septal transfixion; these routine steps in rhinoplasty procedure need no elaboration here. The septal flaps are raised from floor to roof in the manner already described but then the upper lateral cartilages are cleanly cut away flush from their septal attachment (Fig. 8). The deformed ventro-cephalic septal cartilage strut is then straightened as indicated in the horizontal or vertical plane by trimming and crosscutting; and the upper lateral cartilages re-attached by sutures in the corrected position (Fig. 8). In addition to the manoeuvres described for the basic septoplasty, one may then proceed as indicated to expose the lower cartilaginous vault ('Cartilaginous Rhinoplasty') the bony vault, or both vaults ('Septorhinoplasty', a satisfactory though time-consuming single-stage operation) (Patterson, 1966). In this case, in addition to the internal ribbon gauze splint, an external plaster of Paris splint is applied for ten days. Indications for Septoplasty. These have already been discussed earlier. Septoplastic procedure is obligatory in surgical correction of upper cartilaginous vault deformity (Fig. 10), and caudal dislocation (Fig. 9), and in general in all cases where conservation of septal skeleton is considered preferable to its resection. It can safely be applied to young children without fear of distorting naso-facial growth patterns (Fig. 96) (Jennes, 1954). Personal experience and results
The author has practised septoplasty over the past six years and has personally carried out at least 300 operations during this time. No statistical analysis has been carried out. Although there were initially some technically unsatisfactory results due to inexperience (some requiring revision surgery) latterly the procedure has become entirely routine with predictably good results. This has surely been due as much to more adequate understanding and assessment of individual needs, as to increased technical skill at operation. In the author's practice at least 75 per cent of patients requiring septal surgery are booked for some form of septoplasty; only about 25 per cent, with limited midseptal deflections, are submitted now to S.M.R. The proportion of septoplasties is likely to rise further as trainees acquire the necessary technical skill. Comment and conclusions It is not the purpose of this paper to give a detailed historical review of the evolution of the modern septoplasty operation, which began with Metzenbaum's (1929) published work. Many surgeons have made contributions but notable among them have been Fomon (1946, 1948), Goldman (1956), and Cottle (1958, i960). The personal techniques and nomen889
A. (i) Before operation at age 17 years,
(ii) Two months after basic septoplasty. FIG. 9A. Typical Caudal Dislocation of Septal Cartilage.
890
Septoplasty
i. Before operation at age io years, FIG. 9B.
Typical Caudal Dislocation of Septal Cartilage.
891
Nigel Edwards
2. Two years after conservative septoplasty, at age 12 years. FIG. 9B—continued. 892
Septoplasty
(i) Before
(ii) After
FIG. IO.
Upper Cartilaginous Vault Deformity. (i) Before operation, (ii) After Extended Septoplasty—note restoration of contour of nose tip without surgical interference with lower cartilaginous vault (a secondary tip distortion).
893
Nigel Edwards clature described in this paper are unashamedly eclectic but owe much to the ideas of Fomon and of I. B. Goldman. The basic septoplasty technique undoubtedly demands a higher degree of technical skill than the S.M.R. and consistently good results only come with practice; septoplasty is not always suitable for performance by junior trainee otolaryngologists for this reason, and this factor has been found to bring clinical workload problems in its train (O'Brien, 1968). Nevertheless, the advantages to the patient in terms of function of a well-executed conservative septoplasty rather than an S.M.R. are considerable; the post-surgical deformities which are so often seen as the hallmark of an inappropriate S.M.R. should become a thing of the past. Should the septum again require surgical attention later, this is simply carried out, in contrast to the difficult 'revision S.M.R.' with its high risk of septal perforation. The versatility of the method described is obvious; what does need to be stressed is the acknowledgement that the functional and cosmetic aspects of septal surgery are properly indivisible, and the corollary that those who undertake septal surgery should be adequately trained not only in an understanding of nasal physiology but also in the techniques of rhinoplastic surgery. The old distinction between functional and cosmetic nasal surgery should now be considered obsolete. It matters not who carries out the 'new surgery' provided that he is adequately trained in all these aspects—the otorhinolaryngologist would on these grounds appear to be the best equipped for this purpose. Relatively few publications on septoplastic surgery have so far appeared in the British journals—Tepan (1970), Papangelou (1972), Siegler (1973), Maran (1974), and Gilchrist (1974). An expensive leading modern textbook of otorhinolaryngology (Scott-Brown, 3rd edition, 1971) offers no useful practical advice to the septal surgeon on how to tackle these frequent septal problems, using S.M.R. technique. Septoplastic techniques receive no word of mention. This is in marked contrast to the situation in North America and elsewhere. It is to be earnestly hoped that wider instruction of trainees in nasal reconstructive surgery will lead to the recognition which is deserved by septoplasty, to the undoubted benefit of the patient.
Acknowledgements The author's debt to the stimulating teaching of Dr. Irving B. Goldman of Mount Sinai Hospital, New York, has already been mentioned. The valuable help of Mr. Arthur Cottrell, Medical Artist, and Mr. Sweet, Chief Photographer, of the Department of Medical Illustration of Southmead Hospital, Bristol, is here acknowledged with thanks. 894
00
Deformity of all three vaults.
FIG. I I .
(i) Before operation,
o
r-f
FIG. II—continued.
(ii) Six months after Septo-Rhinoplasty—primary nose tip deformity required tip correction.
t
3
Septoplasty REFERENCES ADAMS, G. (1875) British Medical Journal, 2, 421. ASCH, M. J. (1899) Laryngoscope, 6, 340-343. BECKER, O. J. (1951) Transactions of the American Academy of Ophthalmology and Otolaryngology, 55, 244-260. BRIDGER, G. P. (1970) Archives of Otolaryngology, 92, 543. CLARK, G. M. (1967) Archives of Otolaryngology, 85, 418-423. COTTLE, M. H., et al. (1958) Archives of Otolaryngology, 68, 301-313. (i960) Archives of Otolaryngology, 72, 2—12. FOMON, S., et al. (1946) Archives of Otolaryngology, 44, 141-156. (1948) Archives of Otolaryngology, 47, 7-20. FREER, O. (1902) Journal of the American Medical Association, 38, 636-642. FRY, HUNTER (1966) British Journal of Plastic Surgery, 19, 276-278. (1967) British Journal of Plastic Surgery, 20, 146-158. (1967) British J ournal of Plastic Surgery, 20, 392-402. (1968) British J ournal of Plastic Surgery, 21, 170-172. (1968) British Journal of Plastic Surgery, 21, 419-422. GILCHRIST, A. G. (1974) Journal of Laryngology and Otology, 88, 759-771. GOLDMAN, I. B. (1956) Archives of Otolaryngology, 64, 183-189. HAJEK, M. (1892) Internationale Klinische Rundschau, 6, 1419-1423. (1904) quoted by: YANKAUER, S. (1906) Laryngoscope, 16, 303. HUFFMAN, W. C , and LIERLE, D. M. (1957) Plastic and Reconstructive Surgery, 20, 185-198. INGALS, E. F. (1882) Transactions of the American Laryngological Association, 4, 61-69. JENNES, M. L. (1954) Eye, Ear, Nose and Throat Monthly, 33, 586-591. KENEDI, R. M., GIBSON, T., and ABRAHAMS, M. (1963) 'Mechanical Characteristics
of Skin and Cartilage', Human Factors, 5, 525-529. KILLIAN, G. (1904) Archiv fur Laryngologie und Rhinologie, 16, 362-387. (1905) Annals of Otology, Rhinology and Laryngology, 14, 363-393. KRIEG, L. (1889) Berliner Klinische Wochenschrifl, 26, 699. MARAN, A. G. D. (1974) Journal of Laryngology and Otology, 88, 393-405. METZENBAUM, M. (1929) Archives of Otolaryngology, 9, 282-296. (1936) Archives of Otolaryngology, 24, 78-88. O'BRIEN, M. A. (1968) Journal of Laryngology and Otology, 82, 987-994. PAPANGELOU, L. (1972) Journal of Laryngology and Otology, 86, 83-88. PATTERSON, C. (1966) Archives of Otolaryngology, 84, 457-463. PEER, L. A. (1937) Archives of Otolaryngology, 25, 475-477. PROETZ, A. W. (1951) Annals of Otology, Rhinology, Laryngology, 60, 439-467. SCOTT-BROWN'S Diseases of Ear Nose and Throat, ed. Ballantyne and Groves (1971) 3rd edition, Vol. 3, pp. 101 seq. Butterworth. SIEGLER, J. (1973) Journal of Laryngology and Otology, 87, 153-156. SMITHDEAL, C. D. (1968) Southern Medical Journal, 61, 931-938. TEPAN, M. G. (1970) Journal of Laryngology and Otology, 84, 1133-1146. THOMSON, ST. CLAIR (1906) Lancet, 1, 1810-1815. WRIGHT, W. K. (1969) Transactions of the American Academy of Plastic and Reconstructive Surgery, 73, 252-255. YANKAUER, S. (1906) Laryngoscope, 16, 294-309. Litfield House, Clifton Down, Bristol BS8 3LS.
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Laryngology and Otology (Founded in 1887 by MORELL MACKENZIE and NORRIS WOLFENDEN)
September Septoplasty Rational surgery of the nasal septum By NIGEL EDWARDS (Bristol) Summary
THE Submucous Resection (S.M.R.) operation ascribed to Killian, still widely taught as the standard surgical treatment of obstructive septal deformities, has serious deficiencies in many common clinical situations. The reasons for this are critically discussed in the light of the surgical anatomy and physiology of the nose as a whole. The rational, conservative and versatile principle of septoplasty has evolved over half a century, until today the author considers that it should largely supersede the old S.M.R. The principles and the indications for septoplasty are discussed. The basic septoplasty procedure used by the author is described with practical details, together with all the variations and extensions possible as far as a complete septo-rhinoplasty. The importance is stressed of accurate assessment of the whole nasal problem and precise correction of all primary and secondary obstructive factors. Introduction
The earlier surgical manoeuvres used in attempts to correct obstructive septal deformities are well documented elsewhere (Huffman and Lierle, 1957; Maran, 1974); they include forcible 'dilatation' of the nose with septal fracturing and subsequent splinting (Adams, 1875; Asch, 1899), local excision of obstructive projections, and even full thickness resection of portions of the septum. 875
Nigel Edwards The advent of the 'submucous resection' (S.M.R.) therefore represented a notable surgical advance. Although the S.M.R. (or 'fenster-resektion') has long been attributed to Killian (1904, 1905), it would seem likely that surgeons in several centres developed the technique at about the same time—Ingals (1882), Krieg (1889) and Freer (1902) among others should be recognized as pioneers. On reading the clear accounts by St. Clair Thomson (1906) and Yankauer (1906) of the early S.M.R. operation, one is impressed by the fact that little has changed in the technique over 70 years. An operative procedure which has persisted virtually unaltered for so long a time must have considerable intrinsic merit, as Maran (1974) has stated, but there are few who would argue that this limited technique is capable of dealing adequately with many types of obstructive situation of the septum. As early as 1929 and 1936 Metzenbaum reported his limited repositioning technique which can be regarded as the forerunner of modern septoplasty: Peer (1937) added an improvement. In the post-war period, the work of Fomon, Becker, Goldman, Cottle and others has led to a better understanding of nasal physiology and surgical anatomy, and to the evolution of the modern septoplasty concept. In spite of this, inappropriate use of the S.M.R. procedure continues to give some unsatisfactory results, which tend to tarnish the reputation of corrective septal surgery. The following section is devoted to a critical analysis of the role and limitations of the S.M.R.—the more experienced reader may wish to pass directly to the discussion of surgical anatomy and description of septo-plastic procedures. The submucous resection operation of Killian (S.M.R.) is so familiar and well described in standard texts as to require no detailed description here. It permits the subperichondrial and subperiosteal removal of obstructively deviated quadrangular cartilage, and bone of ethmoid plate and vomer; but the borders of the 'free' or mobile portion of the septal cartilage must be preserved intact if certain serious post-surgical sequelae are to be avoided (Figs. 1 and 2). An adequate preserved free margin must be at least 6 to 8 mm. in depth along the caudal and ventro-cephalic borders. The penalties paid later by the patient (Figs. 3 and 4) if the surgeon disobeys these rules, are: (1) Upward recession of the Columella (due to inadequate resistance of the caudal strut) later followed by flattening and 'prolapse' of the nose tip in severe cases. Both events lead to renewed airway obstruction at anterior narial level. (2) Supra-tip depression or 'saddling' deformity (due to inadequate resistance of the ventro-cephalic cartilage strut). Later surgical correction of these avoidable iatrogenic deformities is difficult and often unsatisfactory, due to fibrous contracture of soft tissues and the uncertainty of free tissue grafts. Columellar recession and 876
(b) (c) (d) (e) (/) (g) (h)
(a)
FIG. I.
Nasal Septum—Components septal (quadrangular) cartilage, with attachment of upper lateral cartilage, ethmoid bone, perpendicular plate, vomer, nasal bones with fronto-nasal spine, cribriform plate of ethmoid, sphenoid and sinus, hard palate with maxillary crest, anterior nasal spine.
2.
Nasal Septum after Submucous Resection (i) ventro-cephalic cartilage strut with attached upper lateral cartilages, (ii) caudal cartilage strut, (iii) anterior nasal spine. The broken line indicates the acceptable limits of septal resection. The arrows indicate the lines of tension resisted by the septal catilage struts.
FIG.
en T
Nigel Edwards
FIG. 3. Minor Post—S.M.R. Defoimity. Mild Supratip Depression.
tip collapse is the more difficult problem, particularly if the anterior nasal spine has been removed; the type of S.M.R. attributed to Hajek (1892) and quoted by Yankauer (1906), in which the caudal septal cartilage is resected with the spine, is roundly condemned. 'Supra-tip saddling' or ventro-cephalic marginal depression is more easily disguised by insertion of subcutaneous implants of tissue grafts or foreign material, but some airway obstruction may be hard to correct. The incidence of post-S.M.R. deformity and unsatisfactory functional results tends to be underestimated (although no statistics are available), since they usually do not appear for several months after the patient has been discharged from follow-up. The legitimate applications for the S.M.R. then are the midseptal obstructive deformities where adequately wide (i.e. 6 to 8 mm.) caudal 878
Septoplasty
FIG.
4.
Major Post-S.M.R. Deformity—Supratip Depression. Columellar Recession and Prolapse of Nose Tip.
879
Nigel Edwards and ventro-cephalic struts of quadrangular cartilage can be left intact (Fig. 2). The S.M.R. technique is clearly not suitable for dealing with the following frequently-encountered obstructive or cosmetic septal deformities: (1) The Caudally-dislocated Septal Cartilage ('caudal dislocation') estimated to occur to some degree in at least 50 per cent of adult septal deformities requiring surgery. The large majority of children's septal deformities are of this type. (2) The ventro-cephalic septal cartilage border, with attached upper lateral cartilages, which is bowed away from the mid-line, or serpentine. (3) The ventro-cephalic septal cartilage strut which slopes vertically from the midline [the 'high cartilaginous deflection). Other disadvantages of the S.M.R. procedure are listed as: (a) Loss of normal septal rigidity—the 'flapping septum'—in areas of cartilage and bone resection. (b) Considerable liability to early or later septal perforation in these areas. (c) Weakening of the septum and portions of the nose supported thereby, significant in the event of further traumatic injury to the nose. (d) Technical difficulties of revision surgery where septal cartilage and bone are removed. Septoplasty is here defined as a conservative and versatile system of corrective septal surgery, soundly based on consideration of the surgical anatomy of the whole nose, and having due regard to its physiological functions. Such a system must be adaptable enough to deal with all types of septal deformity—the S.M.R. procedure has been found wanting in this respect. Before practical operative techniques are described, the surgical anatomy of the nose, and the principles underlying successful corrective septal surgery need to be discussed. Surgical anatomy of the nose The disposition of the cartilaginous and bony parts of the nasal septum are illustrated in Figure 1. They are well described in standard texts and need no further description here. The role of the septum as a supporting structure, however, has been the subject of argument over many years, and is today not always clearly understood (Huffman and Lierle, 1957; Wright, 1969). The concept of the nasal cavities being maintained by three separate nasal vaults, each with its own individual relationship to the nasal septum, was clearly stated by Fomon (1946 and 1948) and Becker (1951), and is considered valid and helpful in understanding the important supporting structures whose integrity must be 880
Septoplasty respected by the surgeon. Cadaver dissection will readily confirm these facts (Fig. 5). (i) The bony vault (Fig. 5a) is strong and rigid, consisting of the paired aasal bones and contiguous maxillary processes. The fronto-nasal spine idds an important central strengthening buttress (Clark, 1967). The inderlying nasal septum (bony perpendicular plate of ethmoid, and a >mall part of the quadrangular cartilage) plays no significant supporting •ole in the bony vault.
FIG. 5, The Three Nasal Vaults. A. Bony vault: (i) Nasal bones, (ii) maxillary process, (iii) maxillary crest and vomer, (ivi anterior nasal spine, (v) septal cartilage with upper lateral cartilages removed. B. Upper Cartilaginous Vault: (vi) upper lateral cartilage, C. Lower Cartilaginous Vault: (vii) lower lateral cartilage.
(2) The upper cartilaginous vault (Fig. 56) consists of the paired upper iteral cartilages and their intimate line of medial fusion with the whole if the ventro-cephalic border of the quadrangular septal cartilage from •eneath the nasal bones down almost to the septal angle. Variable ccessory cartilages also lie in this fibro-cartilaginous sheet which lies on . deeper plane and underlaps both the bony vault, to which it is firmly .ttached, and the lower cartilaginous vault to which it has only a loose 881
Nigel Edwards attachment. The lower free margins of the upper lateral cartilages form part of the 'nasal valve', an area of great importance in determining the aerodynamic properties of the nasal air passages (Bridger, 1970). Apart from the relatively narrow upper attachment to the underside of the nasal bones and adjacent septum, and the upper margins of the bony piriform aperture, the upper cartilaginous vault depends for its support on the integrity of the quadrangular septal cartilage. Hence the readiness and ease with which fibrous contracture in the septal flaps can produce a 'supra-tip saddle' if the remaining ventrocephalic septal cartilage strut is not strong enough to resist this tension. The septal and paired upper lateral cartilages in effect form a unit, the 'septo-lateral cartilage'. It is an embryological and morphological entity (Fomon, 1946). The 'keystone' of the arch is the midline junction of the septo-lateral cartilage with the under-surface of the nasal bones (Figs. 1 and 56). This important area may easily be damaged during hump removal and medial osteotomies in the course of a rhinoplasty. (3) The lower cartilaginous vault (Fig. 5c) consists of the paired lower lateral (or alar) cartilages, and overlaps the lower part of the upper cartilaginous vault, to which it has a loose fibrous attachment. Its virtual independence of the upper two vaults allows considerable mobility and sliding movements of the nose tip structures relative to the septum and other vaults. The lateral crura determine the shape of the nasal alae, and functional adequacy of the anterior nares to large extent, being movable by the dilator muscles. The paired domes are joined together to form the nose tip, and the medial crura are likewise closely joined in the columella. It is important to appreciate that the support of the nose tip depends directly upon the correct alignment of the paired medial crura in the columella, and not upon the septum. The caudal part of the septal cartilage, however, plays an important indirect role here, by maintaining the correct alignment of the medial crura, and resisting the upward traction forces of scar tissue (Fig. 2). The aims of corrective septal surgery need now to be defined: (1) Adequate correction of obstructive septal deformity and restoration of function. (2) Surgical correction of secondary effects of septal deformity, which themselves cause impairment of function and which are not expected to revert to normal spontaneously (a) hypertrophic middle turbinates which need physical reduction or outfracturing—an important manoeuvre since the inspiratory air-stream normally passes between middle turbinates and septum (Proetz, 1951), (b) chronically congested and hypertrophic inferior turbinates which need surgical reduction or submucosal diathermy coagulation,
Septoplasty (c) nasal polypi, (d) secondary infective sinusitis, (e) obstructively hypertrophied posterior ends of the inferior turbinates. (3) Preservation of the supportive role of the nasal septum as defined above, and prevention of the usual post-surgical deformities (columellar recession, tip prolapse, supra-tip saddle). (4) Preservation of a firm septum normally capable of withstanding future accidental nasal trauma. (5) Avoidance of a flapping septum devoid of skeletal support and liable to immediate or late perforation. (6) Correction of cosmetic deformities of the columella and of any or all of the three nasal vaults. The author considers the customary distinction and separation of functional aspects of nasal deformity ('the province of the otorhinolaryngologist') from cosmetic aspects ('the province of the plastic surgeon') to be illogical and indeed pernicious. The height of absurdity is reached when a patient with a complex nasal deformity is twice admitted to hospital for surgery in the two different departments; the end-result is often a far-from-ideal compromise. Success in septoplastic surgery demands adherence to certain basic principles which are briefly discussed. (a) adequate surgical exposure involving at least a partial, or often a complete septal transfixion through intercartilaginous incisions, (b) adequate subperichondrial/subperiosteal elevation of flaps on both sides; equally over septal cartilage (which does not require an attached pedicle with blood vessels and indeed survives equally well as a free graft), since tension stresses from fibrous contracture will be as nearly equal and opposite as possible, (c) minimal sacrifice of septal skeletal tissue and lining: trimming and repositioning rather than resection, (d) thorough exposure and surgical freeing of deformed structures from all extrinsic distorting influences, so that natural anatomical relationships are restored by elimination of tension, (e) correction of intrinsic deforming influences in cartilage according to the principles expounded, on the basis of experiment, by Hunter Fry (1966, 1967, 1968), Kenedi et al. (1963), and others. Partialthickness linear cuts on the concave side of a portion of twisted cartilage will allow uncurling of the concavity and gaping of the knife-cuts, due to release of internal tissue tensions in the cartilage. With experience, controlled and stable straightening of complex cartilaginous twists can be achieved. 883
Nigel Edwards (/) correction of deformed bone by precise trimming, or controlled fracturing back into position; it is desirable to leave periosteum attached on at least one side, (g) maintenance of restored and corrected relationships between structures wherever possible by careful internal and external splinting rather than by sutures. Attempted coercion of structures under tension, by sutures or splints, is doomed to failure, particularly with cartilage. The possibility of late recurrence of deformity due to unequal scar tension must always be borne in mind, (h) prevention of undesired overlapping of septal fragments placed edge to edge by fine absorbable mattress sutures transfixing the flaps, passing first between the fragments and on return through the anterior one, (i) careful internal splinting with continuous half-inch petroleum jellysoaked ribbon gauze is left for four days; it accurately maintains the desired tension-free structural alignments, prevents unwanted adhesions, and is easily removable, (k) elimination of infection which is a rare but serious complication —avoidance of haematoma is the best safeguard, but antibiotic cover for a week with penicillin, where appropriate, is routine, (/) use of asteroid-decongestant nasal spray four times daily ('Vasocort') which helps to reduce post-operative reactive oedema after removal of the nasal ribbon pack. Septoplasty: surgical assessment and management
It can not be too strongly emphasized that success in corrective surgery of the nasal air passages depends, firstly, on an accurate preoperative assessment of the problem, and secondly, on choice and precise execution of all the appropriate surgical manoeuvres. It is of limited value to the patient to have a perfect septal repositioning carried out, if other obstructive factors remain unrecognized and untreated.
At anterior narial level, the columella may be excessively wide and flared, or unduly recessive; or the alae may be unduly long and thin, tending to collapse on inspiration. Columellar narrowing or reshaping, or a tip correction to adjust the shape, height, width and angle of the nares may be needed. The silver wire splints of Francis have not proved generally satisfactory in cases of 'alar collapse'. Inside the nose, undue prominence of the anterior pole of the inferior turbinate often needs submucosal diathermy-coagulation, or rarely a subperiosteal resection of bone. In the middle reaches of the nose, careful attention to securing a clear air passage between middle turbinate and septum by 'dilatation' is amply repaid in results. Vomerine spurs are often of minimal significance (Proetz, 884
Septoplasty 1951), except in the pre-sphenoid region where they can cause serious obstruction and should be resected, or trimmed off by osteotome. At choanal level, bulky posterior poles of the inferior turbinates may obstruct, and act as 'ball-valves'; they should then be snared off. Lastly, any sinusitis, polyposis or adenoidal hypertrophy should be dealt with appropriately. The septal problem In the author's clinical experience, obstructive septal deformities fall naturally into three broad categories: (1) The Simple Mid-Septal Deflections—some 25 per cent of cases. There is no caudal cartilage dislocation or high septal deflection, and the S.M.R. technique deals with them adequately. They are not considered further. (2) The Simple Caudal Cartilage Dislocation—some 65 per cent of cases —with or without concomitant midseptal deformity. Septal deformities in children are typically of this type and a 'Conservative Septoplasty' involving minimal sacrifice of cartilage is indicated— in the author's view, age is no contraindication to this procedure if obstruction is severe. In adults some degree of limited midseptal resection is usually combined with the septoplasty. (3) The Complicated Caudal Cartilage dislocation—with one or more of (a) Significant distortion of the Upper Cartilaginous Vault, (b) Deformed tip, unconnected with (a), requiring formal tip correction of Lower Cartilaginous Vault, (c) Deformed bony vault. These cases require (a) Extended septoplasty (Upper Cartilaginous Vault) (b) Cartilaginous rhinoplasty (Upper and Lower Cartilaginous Vaults), (c) Septorhinoplasty (Bony with Upper and Lower Cartilaginous Vaults). (Patterson, 1966; Clark, 1967; Smithdeal, 1968). It is the specific purpose of this paper to describe the surgical techniques embodied in the 'Basic (or conservative) Septoplasty' and the 'Extended septoplasty' procedures. A working knowledge of standard rhinoplastic techniques will make the 'Cartilaginous Rhinoplasty' (embodying tip correction) and 'Septo-Rhinoplasty' (embodying osteotomies and infracture as well as tip correction) readily intelligible to the informed reader. A special variation of the 'Extended Septoplasty' is 'Septoplasty with Total Cartilage Repositioning'; it will not be mentioned further here, but will be the subject of a later publication. 885
Nigel Edwards THE BASIC OR SIMPLE SEPTOPLASTY is the common first stage to all the more extended problems, and is based on the method described by Goldman (1956). Access to the septum is obtained by a limited caudal transfixion incision, from septal angle to base of anterior nasal spine. The columellar base is loosened by blunt scissors dissection, as described by Goldman, and a through-and-through columellar mattress suture ('basal modelling suture') placed to obtain columellar symmetry. The mucoperichondrial flaps are elevated equally on both sides starting close to the anterior nasal spine, and working backwards and upwards to encompass the septal deformity. The flaps are then separated by sharp dissection from the nasal spine and vomer down to the nasal floor. The dislocated septal cartilage is trimmed and cross cut to straighten out concavities, until it is comfortably re-seated on the anterior nasal spine and vomerine groove under no tension (Fig. 6).
A. B. C. D.
FIG. 6. The Basic Septoplasty I. Typical deformity found with caudal cartilage dislocation, Mucoperichondrial flaps being elevated equally on both sides, Corrective partial-thickness cross-cutting; base trimmed, Straightened cartilage splinted to flaps by transfixing mattress sutures which also prevent antero-posterior displacement and overlapping. Cartilage foot anchored to anterior nasal spine.
Oblique-vertical fracture lines, angulated or overlapping, are frequently found; these are best re-opened by the knife, and excess cartilage trimmed off, so that the fragments fit edge to edge without tension. It is usually found convenient in practice to reconstitute the caudal portion of the 886
Septoplasty septal cartilage as two thin mobile independent parallel struts, attached only by a thin pedicle above (Fig. 7)—the pedicle is retained for orientation and not for the sake of its blood supply (Goldman, 1956). One single strut, or three thinner ones, may be fashioned according to local circumstances, but one should aim to retain a total depth of septal cartilage of 10 mm. or more as a caudal buttress for the columella. Behind this buttress a limited midseptal resection may safely be carried out; vomerine spurs may be trimmed off by osteotome. The 'foot' of the caudalmost strut is stitched to the soft tissue left attached to the anterior nasal spine, and there acts as a 'front marker' (Fig. 7).
FIG. 7. The Basic Septoplasty II. (a) Caudal cartilage strut anchored on anterior nasal spine by suture, (6) supporting strut which may be duplicated—note the transfixing mattress sutures which prevent overlapping of struts and splint struts to flaps, (r) 'midseptum' which may be repositioned by trimming and conservative coriection or resected.
The septal repair is commenced by a vertical row of two transfixion mattress sutures of 4 • 0 plain catgut (used throughout) applied by a fine curved Reverdin needle (Fig. 7). The outgoing strand pierces both flaps just behind the back edge of the posterior strut, between it and remaining septal cartilage, returning to pierce the cartilage strut itself. Thus backward shifting of the strut and overlapping is prevented. Similarly a further row of mattress sutures fixes the caudal strut in relation to the posterior strut. The caudal transfixion incision is repaired by mattress 887
Nigel Edwards sutures on a straight cutting needle which behind picks up the edge of the two flaps of the caudal cartilage, and in front picks up the skin edges of the membranous septum attached to the columella. The operation closes with insertion of a continuous internal splint of half-inch ribbon gauze soaked in petroleum jelly, loosely filling both nasal cavities from floor to roof and holding the repaired septum securely in the middle line. It is particularly important that this ribbon splint should be applied accurately between the outfractured middle turbinate and the septum. The splint is removed without trouble after four days, and spraying of Vasocort commenced four times daily, alternatively, silastic sheet splints stitched to the septum may be preferred (Gilchrist, 1974), especially in children, and left in place for several weeks. Antibiotic cover for one week is routine. Rapid uneventful healing is the rule; septal perforation is virtually unknown. THE EXTENDED SEPTOPLASTY (Fig. 8)
This implies extension of the Basic Septoplasty stage described above to include exposure and manipulation of the Upper Cartilaginous Vault,
A. B. C. D.
FIG. 8. The Extended Septoplasty. Upper caitilaginous vault deformity with dorsum deflected to the left, After elevation of dorsal skin, full transfixion, and subperichondrial elevation of septal flaps—upper lateral cartilages are cleanly severed from septal attachment; corrective cross-cuts are shown, Septal cartilage has regained midline position, Upper lateral cartilages reattached to septum by sutuies.
Septoplasty necessitating intercartilaginous incisions, undercutting of the dorsal nasal skin and a full septal transfixion; these routine steps in rhinoplasty procedure need no elaboration here. The septal flaps are raised from floor to roof in the manner already described but then the upper lateral cartilages are cleanly cut away flush from their septal attachment (Fig. 8). The deformed ventro-cephalic septal cartilage strut is then straightened as indicated in the horizontal or vertical plane by trimming and crosscutting; and the upper lateral cartilages re-attached by sutures in the corrected position (Fig. 8). In addition to the manoeuvres described for the basic septoplasty, one may then proceed as indicated to expose the lower cartilaginous vault ('Cartilaginous Rhinoplasty') the bony vault, or both vaults ('Septorhinoplasty', a satisfactory though time-consuming single-stage operation) (Patterson, 1966). In this case, in addition to the internal ribbon gauze splint, an external plaster of Paris splint is applied for ten days. Indications for Septoplasty. These have already been discussed earlier. Septoplastic procedure is obligatory in surgical correction of upper cartilaginous vault deformity (Fig. 10), and caudal dislocation (Fig. 9), and in general in all cases where conservation of septal skeleton is considered preferable to its resection. It can safely be applied to young children without fear of distorting naso-facial growth patterns (Fig. 96) (Jennes, 1954). Personal experience and results
The author has practised septoplasty over the past six years and has personally carried out at least 300 operations during this time. No statistical analysis has been carried out. Although there were initially some technically unsatisfactory results due to inexperience (some requiring revision surgery) latterly the procedure has become entirely routine with predictably good results. This has surely been due as much to more adequate understanding and assessment of individual needs, as to increased technical skill at operation. In the author's practice at least 75 per cent of patients requiring septal surgery are booked for some form of septoplasty; only about 25 per cent, with limited midseptal deflections, are submitted now to S.M.R. The proportion of septoplasties is likely to rise further as trainees acquire the necessary technical skill. Comment and conclusions It is not the purpose of this paper to give a detailed historical review of the evolution of the modern septoplasty operation, which began with Metzenbaum's (1929) published work. Many surgeons have made contributions but notable among them have been Fomon (1946, 1948), Goldman (1956), and Cottle (1958, i960). The personal techniques and nomen889
A. (i) Before operation at age 17 years,
(ii) Two months after basic septoplasty. FIG. 9A. Typical Caudal Dislocation of Septal Cartilage.
890
Septoplasty
i. Before operation at age io years, FIG. 9B.
Typical Caudal Dislocation of Septal Cartilage.
891
Nigel Edwards
2. Two years after conservative septoplasty, at age 12 years. FIG. 9B—continued. 892
Septoplasty
(i) Before
(ii) After
FIG. IO.
Upper Cartilaginous Vault Deformity. (i) Before operation, (ii) After Extended Septoplasty—note restoration of contour of nose tip without surgical interference with lower cartilaginous vault (a secondary tip distortion).
893
Nigel Edwards clature described in this paper are unashamedly eclectic but owe much to the ideas of Fomon and of I. B. Goldman. The basic septoplasty technique undoubtedly demands a higher degree of technical skill than the S.M.R. and consistently good results only come with practice; septoplasty is not always suitable for performance by junior trainee otolaryngologists for this reason, and this factor has been found to bring clinical workload problems in its train (O'Brien, 1968). Nevertheless, the advantages to the patient in terms of function of a well-executed conservative septoplasty rather than an S.M.R. are considerable; the post-surgical deformities which are so often seen as the hallmark of an inappropriate S.M.R. should become a thing of the past. Should the septum again require surgical attention later, this is simply carried out, in contrast to the difficult 'revision S.M.R.' with its high risk of septal perforation. The versatility of the method described is obvious; what does need to be stressed is the acknowledgement that the functional and cosmetic aspects of septal surgery are properly indivisible, and the corollary that those who undertake septal surgery should be adequately trained not only in an understanding of nasal physiology but also in the techniques of rhinoplastic surgery. The old distinction between functional and cosmetic nasal surgery should now be considered obsolete. It matters not who carries out the 'new surgery' provided that he is adequately trained in all these aspects—the otorhinolaryngologist would on these grounds appear to be the best equipped for this purpose. Relatively few publications on septoplastic surgery have so far appeared in the British journals—Tepan (1970), Papangelou (1972), Siegler (1973), Maran (1974), and Gilchrist (1974). An expensive leading modern textbook of otorhinolaryngology (Scott-Brown, 3rd edition, 1971) offers no useful practical advice to the septal surgeon on how to tackle these frequent septal problems, using S.M.R. technique. Septoplastic techniques receive no word of mention. This is in marked contrast to the situation in North America and elsewhere. It is to be earnestly hoped that wider instruction of trainees in nasal reconstructive surgery will lead to the recognition which is deserved by septoplasty, to the undoubted benefit of the patient.
Acknowledgements The author's debt to the stimulating teaching of Dr. Irving B. Goldman of Mount Sinai Hospital, New York, has already been mentioned. The valuable help of Mr. Arthur Cottrell, Medical Artist, and Mr. Sweet, Chief Photographer, of the Department of Medical Illustration of Southmead Hospital, Bristol, is here acknowledged with thanks. 894
00
Deformity of all three vaults.
FIG. I I .
(i) Before operation,
o
r-f
FIG. II—continued.
(ii) Six months after Septo-Rhinoplasty—primary nose tip deformity required tip correction.
t
3
Septoplasty REFERENCES ADAMS, G. (1875) British Medical Journal, 2, 421. ASCH, M. J. (1899) Laryngoscope, 6, 340-343. BECKER, O. J. (1951) Transactions of the American Academy of Ophthalmology and Otolaryngology, 55, 244-260. BRIDGER, G. P. (1970) Archives of Otolaryngology, 92, 543. CLARK, G. M. (1967) Archives of Otolaryngology, 85, 418-423. COTTLE, M. H., et al. (1958) Archives of Otolaryngology, 68, 301-313. (i960) Archives of Otolaryngology, 72, 2—12. FOMON, S., et al. (1946) Archives of Otolaryngology, 44, 141-156. (1948) Archives of Otolaryngology, 47, 7-20. FREER, O. (1902) Journal of the American Medical Association, 38, 636-642. FRY, HUNTER (1966) British Journal of Plastic Surgery, 19, 276-278. (1967) British Journal of Plastic Surgery, 20, 146-158. (1967) British J ournal of Plastic Surgery, 20, 392-402. (1968) British J ournal of Plastic Surgery, 21, 170-172. (1968) British Journal of Plastic Surgery, 21, 419-422. GILCHRIST, A. G. (1974) Journal of Laryngology and Otology, 88, 759-771. GOLDMAN, I. B. (1956) Archives of Otolaryngology, 64, 183-189. HAJEK, M. (1892) Internationale Klinische Rundschau, 6, 1419-1423. (1904) quoted by: YANKAUER, S. (1906) Laryngoscope, 16, 303. HUFFMAN, W. C , and LIERLE, D. M. (1957) Plastic and Reconstructive Surgery, 20, 185-198. INGALS, E. F. (1882) Transactions of the American Laryngological Association, 4, 61-69. JENNES, M. L. (1954) Eye, Ear, Nose and Throat Monthly, 33, 586-591. KENEDI, R. M., GIBSON, T., and ABRAHAMS, M. (1963) 'Mechanical Characteristics
of Skin and Cartilage', Human Factors, 5, 525-529. KILLIAN, G. (1904) Archiv fur Laryngologie und Rhinologie, 16, 362-387. (1905) Annals of Otology, Rhinology and Laryngology, 14, 363-393. KRIEG, L. (1889) Berliner Klinische Wochenschrifl, 26, 699. MARAN, A. G. D. (1974) Journal of Laryngology and Otology, 88, 393-405. METZENBAUM, M. (1929) Archives of Otolaryngology, 9, 282-296. (1936) Archives of Otolaryngology, 24, 78-88. O'BRIEN, M. A. (1968) Journal of Laryngology and Otology, 82, 987-994. PAPANGELOU, L. (1972) Journal of Laryngology and Otology, 86, 83-88. PATTERSON, C. (1966) Archives of Otolaryngology, 84, 457-463. PEER, L. A. (1937) Archives of Otolaryngology, 25, 475-477. PROETZ, A. W. (1951) Annals of Otology, Rhinology, Laryngology, 60, 439-467. SCOTT-BROWN'S Diseases of Ear Nose and Throat, ed. Ballantyne and Groves (1971) 3rd edition, Vol. 3, pp. 101 seq. Butterworth. SIEGLER, J. (1973) Journal of Laryngology and Otology, 87, 153-156. SMITHDEAL, C. D. (1968) Southern Medical Journal, 61, 931-938. TEPAN, M. G. (1970) Journal of Laryngology and Otology, 84, 1133-1146. THOMSON, ST. CLAIR (1906) Lancet, 1, 1810-1815. WRIGHT, W. K. (1969) Transactions of the American Academy of Plastic and Reconstructive Surgery, 73, 252-255. YANKAUER, S. (1906) Laryngoscope, 16, 294-309. Litfield House, Clifton Down, Bristol BS8 3LS.
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