|Year : 2017 | Volume
| Issue : 3 | Page : 61-67
Extracorporeal septoplasty: Role in correction of unilateral cleft nose
BS Jayanth1, Abhitosh Debata2
1 Department of Oral and Maxillofacial Surgery, ABMSS-DCKH Cleft Center, Coorg Institute of Dental Sciences, Coorg, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, Hi-Tech Dental College and Surgeon, Bhubaneswar, Odisha, India
|Date of Web Publication||21-Nov-2017|
B S Jayanth
Department of Oral and Maxillofacial Surgery, ABMSS-DCKH Cleft Center, Coorg Institute of Dental Sciences, Coorg, Karnataka
Source of Support: None, Conflict of Interest: None
Purpose: To evaluate the functional , aesthetic outcomes, and complications associated with extracorporeal septoplasty (ECS) while correcting moderate to severely deviated nasal septum in unilateral cleft lip and palate (CLP) patients. Materials and Method: Fifteen healthy adolescent and adult unilateral cleft lip and palate patients reporting for cleft rhinoplasty procedure to our department and consenting for the research protocol were taken up for study. Result: Mean duration of ECS was 40 minutes. Adequate cartilage graft from excess septum was available for aesthetic and functional requirements in 100% cases. Post-operatively, overall pain scale scores ranged from moderate to no pain. Nasal Obstruction Symptom Evaluation (NOSE) scale scores were significantly low post-operatively in comparison to baseline values (pre – 46.67; 1st Post-operative month – 21.33, 3rdPost-operative month – 16, 6th Post-operative month - 15). The only Intra-operative complicationsnoted were mucosal tear (40%), haemorrhage (6.7%)with absolutely no early or delayed post-operative complications. According to modified-Asher – Mcdade index, nasal form, nasal profile and deviation of nose hadfair to good appearance throughout the case series. Conclusion: ECS is safe and versatile procedure to amply address the septal deformity in all dimensions and offers adequate septal cartilage from the excess septum in cleft nose that can be used as sole graft for all reconstructive requirements in rhinoplasty with improved aesthetics and no additional intra-operative time, cost and complications
Keywords: Asher–Mc-dade index, deviated nasal septum, extracorporeal septoplasty, intracorporealseptoplasty, Nasal Obstruction Symptom Evaluation Scale, unilateral cleft lip and palate
|How to cite this article:|
Jayanth B S, Debata A. Extracorporeal septoplasty: Role in correction of unilateral cleft nose. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:61-7
|How to cite this URL:|
Jayanth B S, Debata A. Extracorporeal septoplasty: Role in correction of unilateral cleft nose. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:61-7. Available from: https://www.jclpca.org/text.asp?2017/4/3/61/218893
| Introduction|| |
The nasal septum is the bone and cartilage in the nose that separates the nasal cavity into two nostrils. The cartilage is called the quadrangular cartilage, and the bones comprising the septum include the maxillary crest, vomer, and the perpendicular plate of the ethmoid and palatine bones. Normally, the septum lies centrally in the nasal cavity, thus rendering symmetrical nasal passages for air flow. In some individuals, however, the septum is deviated which is the most common cause of respiratory obstruction and external asymmetry of the nose. This condition is referred to as deviated nasal septum (DNS). It occurs primarily due to three main etiologies, i.e., congenital, traumatic, and iatrogenic. The prevalence rates of DNS have been found to be around 1%–20% in children, 13% in teenagers (Podoshin et al., 1991; Kawalski and Spiewak, 1998; and Song et al., 1999) with about 80% of adults showing some range of deviation irrespective of ethnicity (Gray, 1978).,, Septal deviation can impact both growth and appearance of soft tissue of the nose as the septum plays a significant role in support and contouring of nose. All unilateral cleft lip and palate (CLP) patients present with a typical deviation of the septum toward the noncleft side, shortening of columellar height accompanied by an overhanging alar cartilage on the cleft side as well as a lateral or laterocranial dislocation of the alar base toward the cleft side with displaced nasal tip and tip ptosis.,
The standard approach to correct the septal deviations was first popularized by Puckett and Wells. However, it is often unsuitable for severe septal deviations in CLP patients causing increased risk of recurrence due to inadequate correction of the deviated septum., In such cases, extracorporeal septoplasty (ECS) has been credited to obtain more reliable outcomes irrespective of few criticisms because of the destabilization of the keystone area., ECS was first discussed in the 1950s by King and Ashley and Gubisch popularized this technique by publishing a large series on the topic in 1995 and described it to be versatile procedure with least possible complications.
Moreover, for addressing the above-mentioned functional and cosmetic problems, excess septal cartilage can be acquired during ECS which can be used as spreader grafts, tip grafts, alar grafting, rim grafts, columellar struts, and shield.
Despite the advantages thus highlighted in various literatures about ECS, yet till date, surgeons have criticized its radical nature, thus resulting in dorsal defects and profile changes. Hence, there is a need to evaluate the functional outcome, esthetic outcomes, and complications associated with the procedure of ECS while correcting DNS in unilateral CLP patients.
| Materials and Methods|| |
Fifteen healthy adolescent and adult unilateral CLP patients reporting for cleft rhinoplasty procedure to the DCKH cleft center and consenting for the study protocol were taken up for the study. We excluded the participants who have previously undergone rhinoplasty. Every patient underwent a presurgical preparation consisting of case history, complete hemogram, physician, and anesthetic evaluation. Radiographic examination (PNS/coronal computed tomography) was performed when there was associated sinus involvement. Informed consent for open rhinoplasty and ECS was obtained from patients. All patients were operated by the same surgeon and observational assistant.
Under general anesthesia, following local infiltration of the nasal tissues, columellar incision followed by rim incision was placed. The domes were divided in the midline, and upper lateral cartilages were released laterally. Submucoperichondrial and subperiosteal dissection of nasal dorsum were performed with dissection proceeding inferoposteriorly. An accurate lateral dissection of upper lateral cartilage was done. The dorsal septum was freed from “keystone” area, where dorsal septal cartilage connects to nasal bones and to perpendicular plate of ethmoid. Once the septum has been freed from its bony attachments, it was removed in toto. Remodeling of the resected septal cartilage was performed depending on the severity of septal deviation. Partial thickness tension-reducing incisions were performed for mild deviations. Cartilage crushing and mattress sutures were performed for moderate-to-severe deviations. Excess septal cartilage from inferioposterior aspect maintaining L-strut is harvested and used as strut, shield, or spreader graft as per the need of the case. The straightened and/or reconstructed septal cartilage was then reimplanted between the two submucoperichondrial flaps. Cephaloposterior advancement of medial crura of lower lateral cartilages onto caudal septum is performed. The medial crura were then fixed to caudal septum ensuring stability and correction of deviation. Once the desired position of dorsum was achieved, transfixing mattress suturing was done to upper lateral cartilage bilaterally to achieve final fixation. Tip plasty can be performed at this stage to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. Thereafter, thin silicon splints were placed along either side of septum cut to fit securely along the floor of the nose and just alongside or slightly posterior to medial crura cartilages. The splints were sutured into place using 3-0 vicryl suture. Additional stabilization was achieved by placing transcutaneous stitches holding the upper septal edge at the border between cartilage and bone. Another similar stitch was placed at the middle body of neocaudal septum to increase midline stability. The operation ends with final closure of the columellar and rim incisions using 4-0 Prolene [Figure 1].
|Figure 1: Intraoperative photographs (a) skin marking and incision, (b) skeletonization and mobilization of septum, (c) deviated nasal septum, (d) scoring of septum, (e) crushing of septum, (f) excess septum acquired for grafting, (g) straightened septum, (h) mucoperchondrial pocket without septum, (i) placement of rectified septum back into the pocket along with grafts (j) final closure|
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Parameters for evaluation
- Functional assessment was done with the help of clinical evaluation by the clinician/surgeon (side of obstruction, discharge, turbinate hypertrophy, and sinus symptoms)
- Nasal Obstruction Symptom Evaluation (NOSE) scale for quality of life assessment was done according to the NOSE instrument protocol [Table 1]
|Table 1: Nasal obstruction symptom evaluation instrument at the final version of nasal obstruction symptom evaluation instrument AAO-HNS 2003|
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- NOSE scale administration is as follows:
- Have patients complete the questionnaire as indicated by circling the response closest to describing their current symptoms.
- Sum the answers the patient circles and multiply by 5 to get the total score ranging from 0 to 100.
- Duration for skeletonization, mobilization, back table work, and placement of the straightened septum back into the mucoperichondrial pocket was noted down
- Mucoperichondrial perforation and hemorrhage requiring surgical intervention, if any, were noted
- The availability of excess septum for use as strut, spreader graft, and shield was noted (If present sufficiently/insufficiently both in terms of quality and quantity).
Standard routine intravenous antibiotics, oral analgesics, and topical decongestants were prescribed in the postoperative Phase for 5 days. Analgesics were given as and when required following the 3rd day.
- Visual analog scale (VAS) was used for noting pain. It was noted in 1st, 3rd, and 5th postoperative day to analyze the degree of patient discomfort following ECS [Figure 2]
- At the end of 1st week, suture removal was done along with clinical assessment of the functioning of the upper airway by the clinician/surgeon during 1st and 2nd week follow-ups
- At the end of 3rd postoperative week (21st postoperative day), nasal splints were removed
- During recall visits, the patients were evaluated objectively by NOSE scale at 1st, 3rd, and 6th month postoperatively
- Complications: Immediate postoperative complications such as hematoma, infection, and necrosis (if any) were noted in the 1st postoperative week. Similarly, delayed complications such as relapse, septal perforation, infection, synechiae, and dorsal irregularities (if any) were noted from 2nd postoperative week to 6th postoperative month
- Evaluation of the esthetic results was done by the two senior professors of our unit by comparing the pre- and post-operative photographs which were taken with DSLR (Canon EOS 1200D) in a standardized manner, thereby maintaining a fixed distance (5 feet), in a standard mode, exposure, and resolution (800 px × 600 px). The frontal and profile two-dimensional images were available for all patients. Pictures were loaded into PowerPoint, and each slide contained profile and frontal view of one patient together with identification number. Only nasolabial area was shown, whereas the surrounding facial features were masked to reduce the influence of background facial appearance. Nasal form (frontal view), deviation of the nose (relative to an imaginary vertical midline between inner canthi taken as midpoint–frontal view), and nasal profile (lateral view) was analyzed using 5-point ordinal scale ranging from 1 to 5, i.e., very good (1) to poor (5), according to modified Asher-Mcdade index.
| Results|| |
- All patients were aged between 16 and 35 years with a mean average of 21 years. Out of 15, 9 patients were female and 6 were male with a male:female ratio of 2:3.11 patients (73.3%) had cleft on the left side and 4 patients (26.7%) had cleft on the right side
- Out of 15, 1 patient had mild deviation, 3 patients had moderate deviation, and rest 11 patients had severely DNS. All patients in the study completed the protocols till end point without any exclusion.
Intraoperatively, mean duration from mobilization of septum until placement of straightened septum back into mucoperichondrial pocket was 40 min (maximum = 55 min and minimum = 30 min) and the mean duration from start to end of procedure was 102 min (maximum = 124 min and minimum = 95 min).
- We encountered mucosal tear in six cases (40%) on the cleft side (left) during skeletonization and mobilization of the septum and the size of tear being <5 mm in all cases. However, it was managed by suturing with 4-0 vicryl. We also experienced an episode of hemorrhage (6.7%) in a patient which was promptly managed by pressure packing. Rest all procedures went uneventful
- In all 15 patients (100%) cases the ECS permitted us to use the septum as a single source of graft harvest in the form of columellar strut, spreader graft, and shield
- VAS for pain recorded considerably low patient discomfort levels with minimal use of analgesics postoperatively [Table 2].
- Until 21 days postoperatively, the patients gave a history of obstructive nasal airflow/congestion. It was primarily because of postoperative edema, crusting, and space occupied by the presence of silicone nasal splints which was managed with the use of nasal decongestants and saline nasal drops.
Frequency of postoperative complications
Zero rate of postoperative complications which means no signs of hematoma, necrosis, inflammatory reactions, relapse, septal perforation, synechiae, and dorsal irregularities [Table 3].
|Table 3: Nasal obstruction and symptom evaluation scale average values of 15 patients|
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- Statistically, the mean difference between pre- and postoperative NOSE scale was 30 and P < 0.001. Hence we can elicit statistically significant difference in pre- and post-operative nasal obstruction [Table 4].
|Table 4: Paired t-test used to compare nasal obstruction and symptom evaluation scale values|
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Cosmetic evaluation of 15 patients by 1st and 2nd observers
The mean scores of all the 3 features are:
- Nasal form (frontal view) – “Good appearance” in eight cases (53.33%) and “fair appearance” in seven cases (46.67%)
- Deviation of nose (frontal view) – “Good appearance” in nine cases (60%) and “fair appearance” in six cases (40%)
- Nasal profile (profile view) – “Good appearance” in nine cases (60%) and “fair appearance” in six cases (40%) [Figure 3].
|Figure 3: Patient photograph (a) preoperative frontal view, (b) postoperative frontal view, (c) preoperative basal view, (d) postoperative basal view, (e) preoperative lateral view, (f) postop lateral view|
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| Discussion|| |
The correction of nasal deformities in CLP patients is considered, particularly difficult because it requires not only knowledge of cleft surgery but also significant experience in functional and esthetic surgery of the nose. Its often forgotten that septum not only plays a pivotal role in function but also has a very vital role to play in supporting the dorsum and nasal tip, therefore bringing into attention that it has over the overall form and structure of the nose. ECS is a procedure of explanting the quadrangular septum out from the confines of the mucoperichondrial pocket such that, under direct vision on the back table, the gross deviation can be corrected to the satisfaction of the surgeon and the excess septum from cleft noses can be harvested from the most appropriate location under direct vision. Numerous challenging studies show that ECS can achieve good results with improved visualization for dissection and reimplantation of rectified septum even in significant deformities of the septum unlike ICS (Rees, 1986; Jugo, 1987; Gubisch, 1988, 1995, 1998, 2005, and 2008)., This study emphasized on correction of moderate severely deformed nasal septum in unilateral CLP patients with the help of ECS and outcome measures were evaluated.
The use of the cartilage grafts reinforces the structural support of the nose, allowing for improved tip definition and preventing wound contracture and collapse. Septal cartilage has several advantages, namely, it is biocompatible, with infection and resorption rates near zero, as evidenced in large reported series. Septal cartilage is easy to carve, and it does not warp over time. Moreover, it is harvested in the same surgical field as the recipient site. Throughout our case series, adequate cartilage graft was available from septum for addressing esthetic and functional requirements of rhinoplasty. Approximately 1.5 cm of strut was left behind caudally and dorsally to preserve support for the dorsum and avoid saddle nose deformity. The excess postero-inferior septal graft was used as strut, spreader graft, and shield to improve the tip projection, tip support, and to address the valve of the nose.
Functional assessment of nose following DNS correction does not require rhinomanometry or computed tomography, and can be adequately assessed with NOSE scale values. In our study, the high preoperative NOSE scale values with a mean of 45 were significantly reduced to a postoperative mean value of 15 at the end of 6 months, with P values being statistically significant. This was made possible by adequately straightening the septum on the back table, the use of spreader grafts on the side of deviation and rectifying tip ptosis with strut, and the neocaudal septum being advanced into the medial crura adding strength to the tip. Somu et al. conducted a single-blinded, case–control study on sixty patients, with Group A undergoing ECS and Group B undergoing conventional septoplasty. He demonstrated that the mean NOSE scale values in Group A dropped from preoperative score of 71.83 ± 22.42 to postoperative score of 9.33 ± 6.40, whereas in Group B, the preoperative score of 75.50 ± 12.69 fell to 20.33 ± 11.30 postoperatively.
The caudal septal cartilage has significant “memory” and will return to its native position during the healing period especially in the case of ICS where the rectification is done under tunnel vision with a good chance of postoperative relapse and persistent nasal obstruction resulting from any under correction thus achieved.
In this study, the septum was scored and crushed under direct vision with proof of straightening. Further with the use of splints, grafts, and suturing of reimplanted septum to the upper lateral cartilage and to the medial crura, there is a great success of septal cartilage straightening and an improved airway in the long run.
Mean intraoperative duration from start of incision to final closure was 102 min (maximum - 124 min and minimum - 95 min) and mean duration from mobilization of septum to placement of straightened septum back into mucoperichondrial pocket was 40 min (maximum - 55 min and minimum - 30 min). In another study thus comparing surgical outcomes in 169 patients where 84 underwent ECS and 85 underwent ICS reported that mean operating time from start of incision to final closure of ECS and ICS were 135 and 128 min, respectively. Hence, it can be concluded that despite the surgical radicalism and distorted anatomy, the ECS procedure does not expose the patient to undue anesthetic morbidity.
The current study was indeed a modification of the original Gubisch technique wherein only the quadrangular septal cartilage was mobilized without osteotomy at the keystone area and this was reflected in our acceptable VAS pain scores and analgesic requirement in spite of the surgical radicalism.
In an era, in which outcome data are growing increasingly critical, little is known about the complications of ECS because only a few articles have published such data. In a study conducted by Gubisch et al. 14l CLP patients underwent ECS and the complications thus encountered was reported as follows: irregular nasal dorsum was reported in seven patients (15%), synechiae in one patient (2%), residual septal deformity in two patients (4%), and septal abscess in one patient (2%). In our study, intraoperatively, we encountered an episode of hemorrhage in one patient (6.7%) which was promptly managed with pressure packing. In six patients (40%), we encountered mucosal tear on cleft side during septoplasty because of the sharp angulations on convex side leading to inadvertent slippage of instruments while releasing the mucosa from the overlying structures. It was easily visualized, accessed, and sutured using 4-0 vicryl. There is a learning curve associated with any new surgical technique, and in cleft patients with distorted anatomy, the very nominal complications that we encountered in this study will be acceptable.
The ultimate goal of correcting a cleft nose deformity is to normalize form, structure, and function. ECS helps in enhancing the nasolabial esthetics by permitting a caudoanterior swing at the anterior septal angle, thereby opening up of the acute angle in a ptotic nose seen in majority of the cleft patients. ECS helps in 3D maneuvering of its position, unlike the conventional endonasal procedure where only a swing door movement can be achieved. Furthermore, by way of choosing the most appropriate site, length, and size of the excess septal cartilage made available in ECS, we get a very robust mechanism to obtain adequate quantity of reconstructive material for strut, shield, or a spreader graft which all go a long way in enhancing the esthetics of the nose overall which could get compromised under the tunnel vision provided by the endonasal approach.
Our study was limited by the small sample size, lack of a control group, lack of objective measurements of functional outcome with modalities such as acoustic rhinometry and no long-term follow-up was present to see for any late relapse.
| Conclusion|| |
ECS is safe and versatile procedure to amply address the septal deformity in all dimensions and offers adequate septal cartilage from the excess septum in cleft nose that can be used as sole graft for all reconstructive requirements in rhinoplasty with improved esthetics and no additional intraoperative time, cost, and complications.
As ECS continues to evolve and simplify, more rhinoplasty surgeons will embrace this surgical method.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]