Article information

Korean J Otorhinolaryngol-Head Neck Surg. 2022;65(7):419-422

Publication date (electronic) : 2022 July 21

doi : https://doi.org/10.3342/kjorl-hns.2022.00367

Cheol Hyo Ku^,*, Eun Jung Lee^,*, Sang Man Park, Ha Neul Lee, Hyun Su Lee, Dong-Joon Park

Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, Wonju, Korea

구철효^,*, 이은정^,*, 박상만, 이하늘, 이현수, 박동준

연세대학교 원주의과대학 이비인후과학교실

Address for correspondence Dong-Joon Park, MD, PhD Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 20 Ilsan-ro, Wonju 26426, Korea Tel +82-33-741-0642 Fax +82-33-732-8287 E-mail rhico@yonsei.ac.kr

^*

These authors contributed equally to this work.

Received 2022 May 9; Revised 2022 June 22; Accepted 2022 June 22.

Trans Abstract

Introduction

A deviated nasal septum is problematic because it causes nasal symptoms including nasal obstruction and other issues such as obstructive sleep apnea and compromised aesthetics. Septoplasty is the most common method for correcting a deviated septum [1,2]. Conventionally, a curved septum is corrected by septoplasty. In principle, septoplasty aims to save a large portion of the cartilage, correct the curved cartilage, and remove the bony deviated portion [3,4]. Correcting the curvature of the dorsal region of the septal cartilage is challenging, as it may affect the stability of the structures supporting the septum. Although several surgical techniques are available, a few are difficult to apply easily. Additionally, the deviation may persist despite the application of the surgical techniques due to rebound memory of the remaining cartilage [5]. In this study, we proposed a horizontal dorsal septal incision of the deviated septum with a mucosal through-and-through suture technique that is performed to secure the corrected cartilage in the designated position in cases of high septal deviation.

Methods

The surgical procedure

Incision and exposure

The surgical procedure is as follows. Under general anesthesia, a modified Killian incision was made on one side of the nasal cavity using a no. 15 blade.

Separation of septal cartilage

After mucoperichondrial flap elevation on the unilateral side of the septum, the inferior cartilage was stripped from the maxillary crest with a knife to mobilize the lower portion of the cartilage. For mobilization of the posterior part of the cartilage, separation of the perpendicular plate of the ethmoidcartilaginous junction was made with a blunt elevator, except for the posterior-superior attachment (at an approximate width of 1 cm from the dorsum, a posterior attachment of the L-strut) to preserve the keystone area (Fig. 1A, black dotted line).

Fig. 1.

Overall description and the effect of the horizontal dorsal septal incision procedure. A: Schematic image of the key steps of the horizontal dorsal septal incision technique. The green solid line represents the preserving area, and the red dotted lines represent the main procedure area of the horizontal dorsal septal incision. B: An area of approximately 1 cm width in the posterior attachment should not be incised to preserve the keystone area. C and D: Illustration of the through-and-through suture technique performed using chromic 5-0 for the entire nasal septum, including the mucosal flap. Pre- and post-operative endoscopic findings. The preoperative (C) endoscopy shows that the septum has severely deviated to the right side. The postoperative endoscopic view shows a relatively straightened septum and a corrected high deviation of the septum at 1-month post-surgery (D).

Horizontal dorsal septal incision for the mobilization of the superior part of the septum

To ensure flexibility and mobilization of the upper attachment of the septal cartilage, an incision was made from the most posterior part of the cartilage to the most anterior end (Fig. 1A, red dotted line). After leaving an approximately 1 cm width in the posterior attachment to preserve the keystone area, the incision was directed upward along the upper end of the cartilage to separate the upper lateral cartilage. Importantly, the highly deviated portion was completely separated from the upper lateral cartilage to provide mobilization while preserving the keystone area (Fig. 1A).

The incision should be made at a cartilaginous depth, and care should be taken not to damage the mucosa opposite side of the flap. Since the only attached and anchored part of the cartilage is opposite side of the mucoperichondrium, considerable attention should be paid to avoid complete detachment. Anterior vertical resection is not routinely performed, but through the horizontal incision itself, the deviated septal cartilage is medialized. Any remaining deviation of the bone or keystone area may be corrected by fracture. Moreover, if the septal cartilage remains deviated after the horizontal dorsal septal incision, it may be corrected through additional scoring, wedge resection, or selective removal.

Suture and finish

A through-and-through suture of the nasal septum, including the mucosal flap, was performed using chromic 5-0 (Fig. 1B). Importantly, this procedure supports the robust correction of any remaining cartilage deviations, by forcibly reducing the rebound memory of the septum. It is crucial to provide adequate suture tension to prevent the restriction of blood circulation. Subsequently, both nasal cavities were packed with a polyvinyl acetate sponge (Merocel^®; Medtronic Xomed Inc., Jacksonville, FL, USA). All patients were provided with analgesics and third-generation cephalosporins and discharged after packing removal on the second day after surgery.

Results

There were 28 adults (25 male, 3 female) enrolled in this study. The mean age was 43.7 years (range: 19-68 years). Of the 28 patients, 21 (75%) had a crooked septum and 7 (25%) also had a bony spur. A horizontal dorsal septal incision was performed in all patients. There was no change in the nasal dorsum or tip shape among the treated patients. There were no significant complications such as saddle deformity, septal hematoma, septal perforation, or nasal tip support problem at the 1-year follow-up (Fig. 1C and D). The preoperative VAS score was 8.21±1.18, and the postoperative score was 2.13± 1.18 (p<0.05), indicating reduced nasal obstruction and improved symptoms. The postoperative VAS scores decreased significantly in all genders and age groups (p<0.05) (Fig. 2).

Fig. 2.

Pre- and post-operative discomfort scores by (A) sex and (B) age. Values are presented as means±standard deviations. *p<0.05.

A deviated nasal septum is a common anatomical variation that causes nasal obstruction. The correction of C- or S-shaped deviated cartilage is difficult, especially in cases with a high deviation [6]. Moreover, if a deviation near the keystone area is removed excessively, the surgeon faces issues due to lack of stability of structures supporting the septum. Therefore, the complete correction of cartilage with high deviation is sometimes difficult [7]. Kang, et al. [8] introduced a method of performing a mattress suture between the perpendicular plate area and the quadrangular cartilage, by causing a greenstick fracture to the upper part of the perpendicular plate. Most of the previous methods focused on the most deviated point, hence these techniques are difficult to apply when there is a diffuse C- or S-shaped high deviation. Here, we introduced a simple and safe surgical technique for patients with a crooked nasal septum with a high deviation.

There have been several methods for correcting deviated nasal septum such as extracorporeal septoplasty, septal batten graft, extension graft, L-strut reconstruction, suture technique, and the use of bioresorbable materials [9]. A problem with these techniques is that additional skills different from those of the traditional nasal septoplasty are required. This renders the techniques difficult for the surgeons to apply. Our proposed method may be a good choice for practitioners who are hesitant to attempt the correction of a high deviation owing to a lack of experience. By separating the highly deviated portion from the upper lateral cartilage, it is possible to distribute the bending vector from the upper part of the septum and correct the nasal septum. Corrections that may be somewhat insufficient in the caudal cartilaginous portion can be supplemented through additional techniques such as the throughand-through suture technique. A horizontal dorsal septal incision along the upper end of the cartilage during septoplasty did not result in postoperative stability problems including saddle nose, tip shape problems, or tip support problems. We found no structural problems to date after 1-year follow-up in patients who underwent the procedure. This suggests that a horizontal dorsal septal incision is a safe and effective method for correcting a high deviation due to a crooked dorsal septum. In the future, our findings should be verified through longterm follow-up studies.

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