THE DEVIATED NASAL SEPTUM—II—PREVENTION AND TREATMENT

By LINDSAY GRAY (Perth, \Y. Australia)

THIS paper is to demonstrate that_the deviated nasal septum can betreated at an early agej and to advocate that treatment should be asconservative as possible.

PREVENTION

By this is implied simple repositioning of the septum by manipulationas soon as possible after the initiating trauma, before fixation of theseptum has occurred in its new position ,_Direct trauma at anv age of lifecan cause the cartilaginous type of deformity of the anterior third of theseptum, with dislocation from the groove on the nasal spine or buckling ofthe cartilage. This simple type is readily amenable to repositioning bylifting the septal tip with Walsham's septal forceps, and manipulating thecartilage back to the midline. Any fracture of the bony arch of the nosemust be reduced initially. If there is present a septal deformity due todeviation of the vomer bone—i.e. the combined type (Gray, 1965), thenmanipulation rarely will give a midline septum.

Over the last 2 years attempts have been made to straighten deviatedseptums by simple manipulation by using a modified Walsham septalforceps (Fig. 1). The blades are 6 mm. wide and 17 mm. long with a simpleblock which only allows closure to 1-5 mm. The technique has been usedon just under 100 cases. These were in two groups—(a) birth to 1 week old(69 cases), and (b) 6 to 24 months old (28 cases). These were selected by thepassing of testing polythene struts as previously described.

Method: No anaesthesia was used for the babies and it does not appearto be warranted, for the procedure takes only 30-40 seconds and the babiesusually settle again within a minute. A general anaesthetic was used for theolder group, as the manipulation was part of a minor operation such asmyringotomy or antral lavage. Thelubricated blades (K.Y. Jelly was theusual lubricant) are inserted or wriggled into the nose and gently closeduntil resistance is felt. (The babe is held by a nurse to prevent unduemovement.) Firm pressure is then exerted caudally on to the middle of thefloor of the nose, depressing the arch of the palate to reduce the initiating

_deformity. No attempt is made to depress the posterior end of the floor, for

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The Deviated Nasal Septum—II—Prevention and Treatment

nH n i i i i i i i i i i i i i i I-... H i i i . i i i i i i i . i t i t i

FIG. I .Modified Walsham Septal Forceps for Infants.

the palatine bones are not involved in the initiating deformity (as postu-lated in 3). To apply the blades along the floor of the nose, the handlesmust be elevated cranially causing a temporary deformity of the softtissues of the nasal tip. The head is held in the left hand (if one is righthanded). The left thumb is applied firmly to the joint of the forceps, thusexerting pressure caudally on the blades, and tends to act as a fulcrumpreventing undue deformity of the nasal tip. The firm caudal pressure iscontinued for 15-20 seconds and the septum is manipulated back to themidline, and then the pressure on the floor is eased and the forcepsremoved. The passageway is then retested and the strut should now passreadily to the back of the nose.

Results: This is a preliminary report, as insufficient time has elapsedand insufficient numbers have been reviewed, but the following observa-tions have been able to be made. Three categories have been reviewed abouta year after the original assessment:

(1) those with septums classified as straight at birth,(2) those classified as bent, and(3) those classified as bent but which had been manipulated.

Categories 1 and 2 have acted as controls for 3.1. Category 1 cases were still predominantly straight although a few

had definite displacements. This is in keeping with the original assessmentwhich only recorded the gross deviations causing frank obstruction and notthe minor irregularities (Gray, 1965).

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2. Category 2 cases all showed considerable deviations to the same sideas originally found, i.e. the testing strut would not pass.

3. Category 3 cases predominantly showed only a little irregularity andthe testing strut passed through to the back of the nose. In some thedeformity was still present. In one there was now a deviation to theopposite side suggestive that during manipulation the deformity had beenover-corrected.

4. Jji the 6-24 month old group over half were improved at operation,but practically all had recurred to a greater or lesser extent by the time ofreviewal. This is explained by referring to Case B of figures 3 and 4 ofmy previous paper (Gray, 1965) which shows a septum of a 6 month oldchild with a permanent bony deformity which could be corrected only bysurgery.

5. Manipulation just after birth in selected cases will prevent develop-ment of a severe combined type of scptal deviation in a high proportion ofcases but is ofjnuch less success if done after 6 months of age.

TREATMENT

It is stressed that with every combined deviation there are alwaysassociated deformities of the lateral walls (turbinates, ethmoid bullae)mainly on the concave side of any septal deviation. This is most likely dueto the reaction of the body attempting to remake the normal anatomy andphysiology of the nose, i.e. as stated by Proetz (1953) "moist slit-likepassages everywhere". This develops pari passu with the growth of theseptal deformity, is readily demonstrated by coronal section of the noseand may be well developed by the age of 6 months (Gray, 1965). Thus thenose must be considered as a WHOLE and attention given to the lateralwalls as well as the septum if normal physiology is to be regained.

The basic reason for operation on the deviated septum is to improve thenasal physiology, and the indication is deviated septum with complica-tions. The complications which may affect the nose, the septum, thesinuses, the ears or the throat are mainly impaired nasal respiration,epistaxis, recurrent sinusitis, nasal polyposis, recurrent throat infectionsand recurrent or chronic ear disease—particularly unilateral ear disease.These will be discussed in a further paper.

Many operations have been devised for straightening a deviated septum,and although authors (Carter, 1930; Goldman, 1952; Wexler, 1955) haveadvocated retention of as much cartilage as possible, the main operationdescribed in the text books is the "Sub Mucous Resection" or S.M.R. Thisentails leaving a skeleton support and filleting out the cartilage and bonyspur. This is a destructive operation and has the well-known potentialcomplications of loss of support of the bridge, flapping and noisy septumand septal perforation; and also is not very suitable for the disorganized

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buckled cartilage tip deformity. However, its main shortcoming is thatbecause it is so destructive it should not be done until the nose has stoppedgrowing. At times, in spite of an obvious need for straightening a septum ina child, no attempt has been made to correct the deformity, thereby oftenallowing irreversible pathological changes to occur in the nose or ears.

The following procedure is an attempt to overcome these disabilities,and has been used in over 300 cases in the last 4 years with very satis-factory results. It has been used for all ages from 4 years old. Technicallyit has been found too difficult to do satisfactorily under 4 years of age.Basically it is a repositioning of the septum done submucosally (see Figs. 2and 3). After mobilization of the septal components by incision, chiselling,fracture and removal of projecting bumps, the pieces of the septum areheld in place by polythene splints (Figs. 4 and 5). A modification of thistechnique has been used on children for the last 12 years without any illeffect on the growth of the nose. It has been possible to observe a nose nowgrowing straight, the disappearance of a columella deformity or theimprovement in nasal physiology.

The technique has been evolved by a certain amount of trial and errorand from perusal of the literature. Its big attribute is that it produces analmost normal anatomical structure in its normal position, and gives thenose a chance to regain its normal physiological function.

Anesthesia: In adults a local anaesthetic is much preferred. Thepremedication is most important. Light nourishment such as tea andtoast is given 2 hours before, together with a sedative (as pentobarb.sodium gr. 3), and 1 hour before—morphia gr. 1/6 if under 10 stone or gr. \if over. The nasal vibrissae are clipped in the ward. The nose is anaesthetizedas for routine S.M.R. The columella is injected with local anaesthetic withadrenalin. If any turbinate is to be reduced it is injected later. By the timethe injection is completed the nose is anaesthetized and ready for theoperation to proceed. With local anaesthetic there is usually very littlebleeding, but with a general anaesthetic the amount may vary from verylittle to an annoying amount.

A general anaesthetic is used for children and selected adults, and thenthe nose is packed with adrenalin gauze and injected as above.

Operation Technique: A headlight with magnification (as Storz loupe)is always used and has been found to give excellent illumination, while themagnification assists greatly the ease and accuracy of handling the tissues.

A vertical incision, a few millimetres behind the front end of thecartilage, is made on the side opposite to the deviation. The perichondriumis elevated, exposing all the tip on both sides. The periosteum is elevatedover the maxillary crest on both sides. The direction of operation is nowaround the tip on to the side of the deviation. The perichondrium iselevated from all the cartilage on that side, for due to the deformity thecartilage extends right to the back over the ethmoid plate on the side of the

Lindsay Gray

FIG. 2.Diagrammatic representation of Sub Mucous Repositioning of the Septum. Note method of

reduction of inferior turbinate with covering over of the raw surface.

FIG. 3.Diagrammatic demonstration showing:

(1) Criss-crossed area—area of removal of cartilage, and trimming or removal of bone.(2) Continuous lines—showing the slatting cuts in the cartilage, some communicating with

the vertical septal cut.(3) Interrupted lines—show lines of bony fracture done either by pressure on the thin bone

or assisted by chiselling.(4) The method of suture around the nasal spine.

spur (Gray, 1965). This leaves the cartilage attached to the perichondriumon the side of the incision. A strip of cartilage (usually about 3-5 mm. wide)is excised from the lower border along the edge of the vomer spur. Thisallows easier access to elevate the periosteum off the vomer (which is thendone), and later allows the cartilage to be brought to the midline withoutinterfering with the vomer. The cartilage is then incised vertically at theanterior edge of the perpendicular plate of the ethmoid, and the cartilageplate thus mobilized is pushed medially, allowing better access. The

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The Deviated Nasal Septum—II—Prevention and Treatment

FIG. 4.To demonstrate the usual position of the splint and strut in each nasal cavity.

FIG. 5.Plastic Splints and Perspex Struts—see addendum for particulars.

periosteum is then separated from the vomer on the other side. The spur isshaved off the vomer or if it is too thick the whole thickness of the bone isremoved. Any projecting pieces are thinned down or removed. The vomeris chiselled along the floor of the nose, and the ethmoid chiselled along theroof so as to enable the bony posterior portion to be infractured to the

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midline. The cartilage is incised through to the perichondrium longitudi-nally to break the spring of the bend. Two cuts are made near the roof toensure that the top will fall easily into the midline. These cuts extend fromthe cut posterior edge of the cartilage to within about 2 cm. from theanterior edge, and parallel incisions are made about i cm. apart on theremainder of cartilage (see Fig. 3). Incisions are made in between thesecuts, extending from about 1 cm. in front of the posterior incision to about1 cm. from the front edge. The pieces of cartilage are held in place by theintact perichondrium and should sit easily in the midline. If the cartilagedoes not, it must be trimmed or slatted further. If there has been dis-organization of the tip, the pieces of cartilage must be mobilized, at timesnearly completely, but left attached to the roof of the nose. The edge of asevere buckle must be excised but as little as possible of the cartilageremoved. The pieces may be held in place by transfixing with straight skinneedles and fixed by using mattress catgut sutures through the mucosa.If necessary, a new bed for the anterior end is made with scissors into thecolumella.

The dental instrument, Ash Sealer No. 152, has been found to be a mostuseful adjunct to the normal instruments.

Drainage incisions are then made through the mucosa on the side of thedeviation at the posterior end and anteriorly near the roof. These are mostimportant as they allow drainage when the splints are in place.

The lateral wall of the nose is then dealt with to bring it into normalalignment with the new position of the septum. This often has to be doneat an earlier stage to allow the septal operation to proceed. As the enlarge-ment of a middle turbinate is often due to enlarged air cells, simplecompression and pushing laterally may be sufficient. The inferior turbinateis incised (Fig. 2) along the edge along the line of the long axis and the boneexposed. The edge of the bone is then reduced by nibbling and the redund-ant lateral quadrant of mucosa is then removed (such as with a Struychen'sNasal Punch). This allows the front flap to fold over neatly. The posteriorend is reduced if necessary.

If there has been a big mucosal tear such as over the spur, the edges areapproximated with catgut suture. This enables primary healing andprotection of the underlying cartilage or bone. If there is a frank loss ofmucosa it can be covered with a flattened out piece of mucosa from thetrimming of the inferior turbinate. This is placed over the area before thesplints are finally inserted and covered with a piece of oil silk which holdsit in place and allows the splints to be inserted without disturbing thegraft. If there is a dip in the nasal bridge due to loss of cartilage support,this often can be rectified by burrowing a hole under the skin from the topof the mucosal incision. It is made above the cartilage and the dip is filledwith fibrous scar tissue and pieces of removed bone and cartilage. Thesplints give support until the septum is firm. Firm pressure by Elastoplast

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The Deviated Nasal Septum—II—Prevention and Treatmentor a plaster of Paris splint keeps the grafts to the bridge moulded intoposition.

The mobile anterior end of the septum is then immobilized to the mid-line by suturing around the nasal spine (Fig. 3). 4/0 Mersilk has been foundmost suitable as it is strong and fine. It is inserted through the cartilageand then back again and through again in a type of figure 8 to preventslipping. It is inserted on a fine No. 5 or 6 eye needle which is held with aGillies (Stille) needle holder so that the needle is in the line of the forcepsand the eye of the needle fits into the slotted blade. It is best held like thisto prevent the needle breaking and to enable the needle to be pushedaccurately and laterally through the septum. The septum is held with finelong plain forceps (as Maclndoe's Forceps 6 in.).

The septum is given its final gentle squeeze and manipulation withWalsham's septal forceps, and the mucosal incision sutured.

The appropriate sized polythene splints (see Fig. 5 and addendum) aregreased and inserted. These should readily slide in and sit easily on eachside. The anterior mattress suture is inserted through the anterior holes,with the splints in situ, using 2/0 Mersilk on a straight skin needle. Thesplints are held in place with the long forceps, which enables the splints tobe accurately positioned in the nose. The splints are removed and theposterior suture is threaded through the splints when they are lying outsidethe nose. 2/0 Mersilk on a No. 5 or 6 eye needle is used, the septum beingheld with the long forceps and the needle held in the Gillies forceps as above.The suture is inserted under direct vision. To insert the needle through theseptum, the needle and blades of the forceps are pushed medially while thehandle is revolved laterally. The needle is then retrieved from the oppositeside, threaded through the splint and then reinserted about 6 mm. abovethe first insertion.

The site, which one judges by experience, is about 2 cm. from theanterior suture and is about the maximum distance back that this cancomfortably be done. The fact that the site of insertion through the septumof the posterior mattress suture does not correspond accurately to theposterior holes on the splints is not important, for the anterior sutureholds the splints accurately in place and the posterior one is just a holdingsuture.

The splints are reinserted and as they are comparatively soft thelongitudinal rigidity is increased by inserting perspex struts (Fig. 5 andaddendum) underneath the sutures (Fig. 4). The splints and struts areheld with the long forceps and the sutures are tied fairly firmly but nottightly (Fig. 4), using the Gillies forceps. The nostrils are packed with well-greased gauze (as Calgetex gauze with Ung. Neomycin).

Postoperatively an antibiotic cover is usually given for 4-5 days, thepacks removed in 24 hours, and the patient discharged on the second day.The nares are toileted by the patient 3 times a day and a small amount of

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ointment applied to prevent drying and crusting. The nose is sucked outand toileted by the surgeon every 2-4 days. The splints, which cause verylittle if any discomfort apart from blockage, are usually removed in 9 or 10days. If there has been disorganization and buckling of the tip they areleft in for 14 days to enable the tissues to thicken up and give support.

Complications are very few.Secondary haemorrhage about the 5th-6th day has occurred in several

cases from the posterior end of the cut inferior turbinate. Although it iseasy to arrange for the flap to cover over the cut edge in the anterior part,it is difficult to do so accurately at the posterior end and thus a raw surfacemay be left. Treatment entailed removing the strut on that side and thehaemorrhage was readily controlled by the use of an inflatable nasal bag(as Down Bros L 62-1). In one case the posterior end of the spur near thesphenoid had not been sufficiently reduced, and the posterior end of thesplint caused irritation and bleeding. This required removal of the splintand strut. This would be suspected if haemorrhage occurred on the oppositeside to the reduced inferior turbinate.

Perforation is unlikely to occur because of the strength of the fullthickness of a normal septum. A perforation has occurred in the superiorportion above the splints but not since an adequate drainage incision hasbeen made, as mentioned above.

A tendency for the buckle to recur is prevented by ensuring that theseptum sits in the midline after slatting and mobilizing the septum, and bythe suture around the nasal spine.

The splints cause very little reaction and inconvenience and in twocases when left in situ for 3-4 weeks, no infection or nasal reaction occurred.

The operation is time consuming—taking i | to 2 hours.Although this technique is applicable to all cases at all ages, particular

mention is made of its use in the following types:1. All children.2. The septal deformity associated with cleft lip and palate. Attention

to the combined type of deviation of the septum improves the airway, andrepositioning of the deformed anterior part of the cartilage may elevate thetip, improving the appearance and also modifying the requirements offurther plastic surgery. Therefore this should be done in association withthe plastic surgeon and before secondary surgery on the nasal openings isperformed.

3. The post-traumatic deformed anterior 1/3 of the cartilage—theso-called concertina deformity—and the associated depression of thebridge.

4. Septal haematoma with or without abscess formation: The mucosa isincised horizontally low down and the clot and infection sucked out and adrainage incision is made at the top of the septum. If a marked septal spuris present, a routine septal approach and removal of the spur can be done.

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The Deviated Nasal Septum—II—Prevention and Treatment

The septum is squeezed and manipulated and then splints tied in as forroutine septal operation. The splints are left 14 days and support thethinned cartilage and allow the septum to become firm.

Summary

1. Although this is a preliminary report, it is put forward thatjnanipu-lation of the septum just after birth, in cases selected_by passing a testingpolythene strut, will prevent in a high proportion of them, the develop-ment of a combined type of septal deformity.

2. Manipulation will only have a small measure of success if donebetween the ages of 6 and 18 months.

3. The nose must be considered as a WHOLE and attention given to thelateral walls as well as the septum if normal physiology is to be regained.

4. A surgical_technique called sub mucous repositioning of the septumis described which is applicable to all ages over 4 years. Basically it isrepositioning of the septum after it has been mobilized submucosally. Theseptum is held in position by polythene splints which are described.

5. This technique is particularly applicable to:(a) all children,(b) cleft lip and palate cases,(c) post traumatic deformity of anterior end of septum,(d) infected septal haematoma.

Acknowledgment

Grateful acknowledgment is made to Mr. R. Plummer and his associ-ates of the Photographic Department of the Sir Charles Gairdner Hospitalfor the reproductions.

Addendum

Polythene splints are made from Regular Polythene sheeting i/i6thinch. Two pairs of holes are about 6 mm. apart. The anterior pair arefabout8 mm. from the front end and the posterior pair 16 to 18 mm. further backfrom the anterior holes.

DIMENSIONS OF SPLINTS.

No.

i

2

345

Length

51 mm.51 mm.58 mm.58 mm.65 mm.

Height

14 mm.17 mm.17 mm.20 mm.20 mm.

Usual Age

4-6 yrs.5-8 yrs.8-12 yrs.

Over 11 yrs.Adult

Strut

44 mm.44 mm.48 mm.48 mm.54 mm.

Perspex struts are made from Perspex sheeting 1-5 mm. thick and are 5 mm. wide.Lengths are 54, 48 and 44 mm. long.

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Lindsay GrayREFERENCES

CARTER, W. W. (1930) Ann. Otol. (St. Louis), 39, 199.GOLDMAN, I. B. (1952) / . Int. Coll. Surg., 17, 167.GRAY, L. P. (1965) / . Laryng., 79, 567.PROETZ, A. W. (1953) Essays on the Applied Physiology of the Nose. 2nd edition.

St. Louis.WEXLER, M. R. (1955) / . Amer. med. Ass., 157, 333.

Lindsay P. Gray,194 St. George's Terrace,Perth,Western Australia.

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