A 3-year-old child with a severely deviated septum and airway obstruction.

Abstract

Otolaryngologists recognized more than 100 years ago that radical surgery or severe injury to the pediatric nasal septum could result in substantial abnormalities of nasal and maxillary growth. Starting in the mid-1800s, studies of young pigs, rabbits, goats, dogs, and cats have shown consistently that removal of full-thickness portions of the growing nasal septum can lead to growth retardation of the palate, nasal dorsum, maxilla, and premaxilla and to malocclusion. This observation contributed to the view that the vomeroseptal junction was an important nasal growth center and that, in general, septal surgery should be avoided in young children. Human studies of pediatric patients undergoing septorhinoplasty are confounded by the previous traumatic injury presumably leading to the septal deviation and by the subsequent airway obstruction. It is impossible to know for sure whether any postsurgical growth retardation was due to the initial trauma, the airway obstruction, or to surgical trauma. For example, Bejar et al described 28 patients aged 6 to 15 years who underwent septoplasty for severe deviation with airway obstruction. The procedure consisted of elevating mucoperichondrial flaps, removing the septum, and then reshaping and replacing it. Fortyeight percent of patients were thought to have abnormally small noses on their preoperative photographs. All patients were analyzed with a set of 12 anthropometric measurements at an average of 3.4 years postoperatively. The most common finding at follow-up was a short nasal dorsum. While nasal dorsal length was within 1 SD of normal in 20 patients (71%), it was optimal in only 10 (36%). Similarly, Crysdale and Tatham reported on a series of 15 patients aged 6 to 17 years who had undergone external septorhinoplasty for severe dorsoseptal deformities. Five of the 15 at long-term follow-up were felt to have fair or poor results. Again, it is impossible to determine how much growth retardation was due to the initial trauma responsible for the dorsoseptal deformities. Jugo also has described long-term follow-up in a series of 24 patients aged 5 to 14 years following external septorhinoplasty. In his technique, the septal cartilage was completely removed by detaching it from the upper lateral cartilage and from the maxillary crest. It was then reshaped and replaced with suturing to the upper laterals and nasal tip. He noted “mild saddling deformity” with loss of tip support in 3 patients (12.5%) with evidence of severe prior distal septal injury. One patient, operated on at age 10, did well for 4 years but demonstrated obvious decreased growth of his nose and midface at puberty. Compelling evidence for the role of the nasal septal cartilage in nasal growth is provided by the few identical twin studies in the literature. For example, Grymer and Bosch describe a pair of identical twins observed from age 7 years, when twin A sustained a nasal septal fracture with hematoma and cartilage loss, through age 17 years. The septal hematoma was initially drained and the cartilage defect repaired with homologous septal cartilage from a tissue bank. The patient was also found to have a vertical fracture at the bony cartilaginous junction and a horizontal fracture through the middle of the residual cartilage. At age 17 years, the twin pair was assessed using cephalometric measurements and facial photographs. Compared with his brother, twin A showed substantial decrease in the distance from the anterior nasal spine to the rhinion and decreased nasal projection. He demonstrated diminished anteroposterior maxillary projection with upward rotation of the anterior maxilla. The authors concluded that the cartilaginous nasal septum seems to be an important factor in determining vertical and anteroposterior maxillary growth.