Septal Deformity Research Articles

Concha bullosa and the nasal middle meatus obstructive syndrome

Concha bullosa (CB) is pneumatization of the middle turbinate and one of the most common anatomic variation of the sinonasal region. It is found in about 25% of the population. Middle meatus obstructive syndrome (MMOS) is, usually connected with CB. The main symptoms of this syndrome are headaches, impaired nasal breathing and hyposmia. Headache is the most common symptom and it may occur due to contact between a CB and other structures of the nasal cavity. We presented a case of 32 year-old-woman with headaches, located in the orbital and the left frontal region. The headaches were intermittent and corresponding to the nasal cycle. After neurologic and allergic examination, endoscopic nasal examination demonstrated a septal deviation to the right side and a large middle turbinate in the left side of the nasal cavity. Coronal computerized tomography (CT) of the paranasal sinuses demonstrated the septal deformation and pneumatization of the left middle turbinate. Diagnosis was confirmed by lidocaine test. In the functional endoscopic surgery (FESS), the lateral lamela of the anterior CB was removed. At the same time, the septoplasty was done. At the control examination, the patient was without symptoms. Although CB is the common anatomic variation of the nasal cavity, MMOS is rare. Headache (rhinogenic origin) is the most important symptom. Surgical treatment is the lateral resection of the CB in the FESS technique and the septoplasty.

RETRACTED ARTICLE: New and Detailed Classification of Saddle Nose Deformities: Step-by-Step Surgical Approach Using the Current Techniques for Each Group

Currently, saddle nose deformity is one of the most challenging deformities in all of rhinoplasty surgery. Recent advances in aesthetic reconstructive surgical techniques warrant discussion of this subject. A review of saddle nose cases from January 2003 to February 2007 showed that the existence of an important subgroup exists, designated as septal saddle nose deformity. The pathophysiology was weakening or loss of septal support, bone, or both, but not the classic dorsal overresection. A prospective study of 33 consecutive cases was completed, with emphasis on analysis, classification, and treatment. Prior attempts at classification have emphasized cause. The author’s study indicated that the majority of cases had multiple causes, the most common being trauma followed by septorhinoplasty (immediately or later), as opposed to simple fracture reduction. In addition, 23 of 33 cases were true secondary saddle nose deformities. Classification was divided into types. Different methods of composite reconstruction were devised according to each case and grade, which allows construction of a deep structural foundation layer that then is superimposed with an aesthetic layer. Septal saddle nose still is an important entity that must be recognized and treated, especially when it is progressive. Composite reconstruction offers a unique solution to saddle nose deformity because it is a flexible method of restoring structural support and aesthetic contour.

Columella stabilising suture

Caudal septal deformities if uncorrected can lead to poor functional and cosmetic outcomes. Adequate fixation of the septum to the maxillary spine is paramount in correcting these deformities. We describe a simple technique for securing the caudal septum to the maxillary spine that stabilises it in all three planes.

Radiofrequency current delivery via transseptal needle to facilitate septal puncture

Transseptal catheterization is a technique that has been used since the late 1950s to gain percutaneous access to the left atrium (LA). 1 De Ponti R. Zardini M. Stori C. Longobardi M. Salerno-Uriarte J.A. Trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias. Eur Heart J. 1998; 19: 943-950 Crossref PubMed Scopus (82) Google Scholar With the advent of catheter-based approaches to intervene on diseased mitral valves and cardiac arrhythmias, the need for access to the LA has increased. At present, multiple modalities including traditional fluoroscopic guidance and intracardiac pressure monitoring with either transesophageal echocardiography or intracardiac echocardiography (ICE) are available to assist transseptal access. 2 Daoud E.G. Transseptal catheterization. Heart Rhythm. 2005; 2: 212-214 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Despite increased operator experience and better visualization when performing transseptal catheterization, there are several clinical settings in which crossing the septum is very difficult or impossible. 3 Marcus G.M. Ren X. Tseng Z.H. Badhwar N. Lee B.K. Lee R.J. Foster E. Olgin J.E. Repeat transseptal catheterization after ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2007; 18: 55-59 Crossref PubMed Scopus (60) Google Scholar These include patients undergoing repeat transseptal access, patients with cardiac surgical repair involving the interatrial septum, or patients with anatomic variants including lipomatous or aneurysmal interatrial septal deformity. To overcome these challenges, techniques that use active methods such as dedicated radiofrequency (RF) systems to perforate the septum and other cardiac structures have been developed and used clinically. 4 Justino H. Benson L.N. Nykanen D.G. Transcatheter creation of an atrial septal defect using radiofrequency perforation. Catheter Cardiovasc Interv. 2001; 54: 83-87 Crossref PubMed Scopus (48) Google Scholar , 5 Benson L.N. Nykanen D. Collison A. Radiofrequency perforation in the treatment of congenital heart disease. Catheter Cardiovasc Interv. 2002; 56: 72-82 Crossref PubMed Scopus (31) Google Scholar , 6 Pedra C.A. Filho R.M. Arrieta R.S. Tellez R. Fontes V.F. Recanalization of a discrete atretic right pulmonary artery segment with a new radiofrequency system. Catheter Cardiovasc Interv. 2003; 60: 82-87 Crossref PubMed Scopus (8) Google Scholar

Deviation of the nasal septum is one of the common causes of nasal obstruction

In Japan, the majority of surgical cases of deviated nasal septum are treated via Killian's submucosal incision technique. With this method, however, incision is made directly over the septal cartilage and the caudal end is not exposed, therefore the deformity around the caudal end cannot be corrected. It has been believed that, in Japan, few patients with nasal obstruction have stenosis in the nasal valve area, but some cases do exist. We treated the nasal septum deviation of such cases via the maxillapremaxilla approach as described by Cottle. With this method, we could obtain good visualization of the nasal septum structure and correct the septum deformity around the nasal valve. This method is also applicable to difficult cases such as traumatic deformity of the nasal septum and a second approach after surgical failure.

Nasal Base Narrowing

To evaluate the role of the combined alar base excision technique in narrowing the nasal base and correcting excessive alar flare. The study included 60 cases presenting with a wide nasal base and excessive alar flaring. The surgical procedure combined an external alar wedge resection with an internal vestibular floor excision. All cases were followed up for a mean of 32 (range, 12-144) months. Nasal tip modification and correction of any preexisting caudal septal deformities were always completed before the nasal base narrowing. The mean width of the external alar wedge excised was 7.2 (range, 4-11) mm, whereas the mean width of the sill excision was 3.1 (range, 2-7) mm. Completing the internal excision first resulted in a more conservative external resection, thus avoiding any blunting of the alar-facial crease. No cases of postoperative bleeding, infection, or keloid formation were encountered, and the external alar wedge excision healed with an inconspicuous scar that was well hidden in the depth of the alar-facial crease. Finally, the risk of notching of the alar rim, which can occur at the junction of the external and internal excisions, was significantly reduced by adopting a 2-layered closure of the vestibular floor (P = .01). The combined alar base excision resulted in effective narrowing of the nasal base with elimination of excessive alar flare. Commonly feared complications, such as blunting of the alar-facial crease or notching of the alar rim, were avoided by using simple modifications in the technique of excision and closure.

Septopalatal Protraction for Correction of Nasal Septal Deformity in Cleft Palate Infants

Septopalatal Protraction for Correction of Nasal Septal Deformity in Cleft Palate Infants

Isolated large atrial septal aneurysm and multiple cerebral infarcts: Is there any association?

An atrial septal aneurysm (ASA) is a thin, localized saccular deformity of the atrial septum that bulges into the right or left atrium. Diagnosis can be established using transthoracic (TTE) and transesophageal (TEE) echocardiography. Although these abnormalities are considered clinically benign entities, they have been independently associated with ischemic stroke. The case of a large atrial septal aneurysm in a patient with transient ischemic attack and previous undiagnosed cerebral infarcts is described in the present report.

Rhinoplastic techniques for the nasal valve for the patient with sleep apnea

Treatment of nasal blockage is necessary to facilitate therapy of obstructive sleep apnea and improve continuous positive airway pressure tolerance. The importance of the nasal valve in controlling inspiratory airflow has been well documented. Defining the nasal valve region and correlating physiology with its anatomic and surgical findings can be confusing. Reliable interpretation of the different types of nasal valve dysfunction can be correlated with effective surgical repair to reduce nasal airway resistance. A simplified approach to standardizing surgical treatment of nasal valve problems is presented.

Closure of nasal septal perforation via endonasal approach

We report our experience in nasal septum perforation surgery using the endonasal approach. The role of rhinomanometry and nasal endoscopy in the management of septal perforation repair is also discussed. We reviewed a sample of 30 patients with septal perforation. Patients underwent preoperative and postoperative nasal endoscopy and rhinomanometry. They were all treated using the Cottle technique with the backward extraction-reposition of nasal septum and inverted sliding flap suture technique. Closure rate for small-sized and middle-sized perforations was 94% and 75%, respectively. It was 86.6% if calculated for all patients. Preoperative nasal resistances was normal in patients with isolated septum perforation, and high in patients with associated septum deformity or hypertrophic turbinates. The Cottle technique is a viable procedure for the closure of small- and middle-sized perforations. Endoscopy and rhinomanometry help provide a correct and complete understanding of this nasal alteration.

Twenty-Five Years Experience with Extracorporeal Septoplasty

Even today, the difficult septum presents a surgical problem. A severe septum deformity is caused mostly by an accident or is seen in patients with malformations such as cleft lip and palate deformity. It is characterized by a massive malformation in all levels with consecutive blocking of one or both airways. Such marked septal deformities cannot be corrected properly by standard septoplasty techniques. Therefore, in such cases we suggest an extracorporeal septoplasty, where we take out the whole septum and reconstruct a new septal plate by different techniques followed by replantation and reconstruction of the cartilaginous dorsum. From January 1, 1981 to December 31, 2005, we operated on 2301 patients and improved this method constantly, especially the safe septal fixation and rebuilding of the cartilaginous dorsum. Follow-ups showed that even in severe deformities a revision rate of only 5% respectively 7% was found. Therefore, we conclude that the extracorporeal septoplasty with its refinements and the way we are doing it today can also be recommended to less experienced rhinosurgeons.

Scar Flap for Extension of the Nasal and Lip Soft Tissue Shell in Secondary Cleft Deformities

A scar flap is formed with the pedicle at the lateral part of the columella base at the cleft side, that is, in the center of the affected region. It enables flap placement according to individual need. A prospective evaluation was performed in a group of 76 patients with cleft lip and palate, all operated on by the same plastic surgeon. The flap was used to improve the height of the columella and the extent of nasal mucosa on the frontal septum and on the nostril base in the vestibule. In the lip, the flap raised its height and improved proportionality. The average area of flap used in a unilateral deformity was 42 mm. Both flaps in a bilateral deformity were 77 mm. The average follow-up was 22.4 months. Neither local nor general complications were noted apart from a recurrence of the deformity of the nasal septum in 7.9% of patients. The nasal passage was improved in 59.9% of patients and normalized in 19.6% upon follow-up rhinomanometry, but nevertheless, only one third of patients overcame their dynamic stereotype of breathing by the mouth. Anthropometric measurements showed an absence of statistically significant differences between patients after surgery and healthy individuals in crucial parameters (nasal tip projection, length of columella, nasolabial angle, nasal angle, and lip angle). The loss of the stigmatizing deformity is based on rotation of the nasolabial angle in relation to the aesthetic axis of the face. Direct examination proved aesthetic and functional improvement as statistically significant in 92.1% of patients.

Reconstruction of Dorsal and/or Caudal Nasal Septum Deformities With Septal Battens or by Septal Replacement: An Overview and Comparison of Techniques

The objectives of this study were to describe and compare two techniques used to correct nasal septum deviations located in the dorsal and/or caudal septum. The authors conducted a retrospective clinical chart review. The authors conducted a comparison of functional and technical results between surgery in the L-strut of the septum in 114 patients with septal battens or by septal replacement by subjective self-evaluation and by examination of the position of the septum during follow up. There was subjective improvement in nasal breathing in 86% of the septal batten group and in 94% of the septal replacement group. This difference was not statistically significant. The technical result was judged by examining the position of the septum during follow up as midline, slightly deviated, or severely deviated. The septum was significantly more often located in the midline during follow up in the septal replacement group than in the septal batten group. Treatment of deformities located in the structurally important L-strut of the septum may be technically challenging and many functional, structural, and esthetic considerations must be taken into account. On the basis of this series, both septal battens and septal replacement techniques may be considered for correction of deviations in this area. The functional improvement rates were not significantly different between the techniques, although during follow up, the septum appeared to be significantly more often located in the midline in the septal replacement group. The techniques are described and their respective advantages and potential drawbacks are discussed.

Septal Cartilage Defined: Implications for Nasal Dynamics and Rhinoplasty

Although the septal cartilage is integral to structural nasal stability, it is routinely violated during septorhinoplasty. This occurs during dorsal hump reduction, caudal septal reduction, submucoperichondrial resection of a deviated septum, or harvesting of cartilage graft material. Despite such routine alteration and/or use, the characteristics of septal cartilage have not been adequately defined. By measuring septal length, height, and cartilage thickness mapped out at 5-mm intervals over the entire nasal septum in 11 fresh cadaver specimens, the characteristics of septal cartilage were determined. Septal thickness measurements demonstrated significant differences along the nasal septum, with the greatest thickness along the septal base (2.7 +/- 0.1 mm), followed by intermediate thickness along the septal dorsum (2.0 +/- 0.2 mm) and the least thickness along the central portion (1.3 +/- 0.2 mm) and at the anterior septal angle (1.2 +/- 0.1 mm) (p < 0.001). These observations clarify several nuances regarding septal structural stability, septal deformities, and the effects of septal alteration during rhinoplasty. The findings of this study reinforce several principles, including recognition of factors contributing to the high propensity of acquired central septal perforations; preservation of a generous L-strut width, especially at the anterior septal angle, or if planning dorsal hump reduction, prudent allocation of harvested septal cartilage; and clarifying the proclivity for supratip deformity following rhinoplasty.

The nasal septum deformities in children and adolescents from Warsaw, Poland

The final shape of the nasal septum deformities is a result of irregular development of the nasomaxillary complex or of a nasal injury. Nasal septum deformities reveal in childhood. The aim of this study is to estimate the prevalence of the particular types of the septum deformities in children according to Mladina's classification, analysis of the correlation between types of deformities and age and sex and checking if nasal injury influences the occurrences of nasal septum deformities and determines the particular type of it. The nasal septum morphology was examined in 288 children aged 3-17. The investigation was performed in kindergartens and schools in Warsaw. The study population was divided into three groups. Anterior rhinoscopy without nasal vasocontrictive drugs was performed. A questionnaire was included. The nasal septum deformities were qualified according to Mladina's classification. Analysis of variance (ANOVA) and Wilcoxon's test were used to performed statistical significance. Deviation of the nasal septum was diagnosed in nearly 34% of the sample population. The nasal septum deformities occurred in 29% of girls and in nearly 37% of boys. The prevalence of septum deformities in group 1 aged 3-7 years was 35.23%, in group 2 aged 8-13 years was 27.97% and in group 3 aged 14-17 years was 40.24%. We observed statistically significant correlation between age of patients and type of nasal septum deformities (F=3.65, p=0.000876). In children with nasal injures, 66.66% had nasal septum deformities while in group without injuries there was about 31.69%. We observed statistically significant correlation between type of nasal septum deformities and nasal injuries (Z=7.67, p<0.0000001). The percentage of the nasal septum deformities change with age. Deviation of the nasal septum was more prevalent in boys. The risk of occurrence of the nasal septum deformities increases after nasal injury. Type 1 and type 5 according to Mladina's classification dominates in study population. Type 1 decreases with age, while type 5 increases with age.

Septoplasty in children

Surgery to correct nasal abnormalities in children has significant implications in the treatment of sleep disordered breathing, especially obstructive sleep apnea and snoring. Septal deformity can contribute to significant nasal obstruction, and failure to address this problem in the treatment of children with sleep disordered breathing will usually result in recurrence of symptoms. Preoperative considerations and a simple technique in performing septoplasty are discussed.

Septopalatal Protraction for Correction of Nasal Septal Deformity in Cleft Palate Infants

It is proposed to test the practicality of septopalatal protraction in the unilateral cleft palate infant for purposes of straightening the nasal septum and thus relieving nasal airflow obstruction and its detrimental sequelae. Alternate infants affected with complete unilateral palatal clefts had septopalatal protraction for a period of 6 to 8 weeks (protraction group; n = 4). Septal deviation was measured by a standardized technique that used computed tomography scans. The remaining infants had no protraction and served as controls (nonprotraction group; n = 5). Septal deviation was measured in the nonprotraction group from palatoseptal dental molds. A total of 9 patients were studied. All patients in the nonprotraction group had worsening of nasal septal deviation over a period of 8 weeks compared with the protraction group, which had complete nasal septal straightening. Differences in septal angle deviation between the protraction group and nonprotraction group at the end of the study were statistically significant (P < or = 0.01) as measured by the paired Student t test. Septopalatal protraction in the newborn appears to provide a means for correcting nasal septal deviation in complete unilateral cleft palate infants. Septopalatal protraction in the newborn is relatively easy and safe.

Powered Endoscopic Nasal Septal Surgery.

While nasal endoscopy is typically used for diagnosis and sinus surgery, endoscopy can be combined with powered instrumentation to perform nasal septal surgery. Powered Endoscopic Nasal Septum Surgery (PENSS) is an easy, effective and quick alternative to traditional headlight approaches to septoplasty. PENSS limits the dissection to the area of the deviation and markedly reduces the extent of subperichondrial dissection. This is particularly valuable in patients who have undergone prior septal cartilage resection. PENSS was used in 2,730 patients over 8 years. Surgical indications and technique are discussed. These patients had either isolated nasal septal deformities associated with other rhinologic pathology (sinusitis, adenoid hypertrophy polyps and external nasal deformity). PENSS was utilized with video assistance to allow an enhanced view of the endoscopic operative field. These patients were operated upon in an outpatient surgical suite and were seen for a post-operative video endoscopic evaluation at 5, 10, 15 and 20 days after surgery. The patients who had associated functional endoscopic sinus surgery were evaluated as needed until 6 weeks after surgery. There were no delayed complications. Endoscopic resection of septal spurs, deformities and deviations can be performed safely alone or in combination with endoscopic sinus surgery with minimal additional morbidity.

Objective versus Subjective Outcomes Assessment in Rhinology

Prior studies on the relationship between computed tomography scan findings and patient-based quality of life in chronic rhinosinusitis (CRS) have found very low correlations. Whereas surprising, similarfindings have been noted in other diseases. We performed a cross-sectional analysis of the association between objective and subjective findings in nasal septal deformity and a systematic review and synthesis of the literature on CRS and other diseases. We found no association between objective anatomic findings and subjective symptoms in nasal obstruction (R = 0.03; Kruskal-Wallis test, p = 0.97). Multiple studies in CRS and other diseases-sleep apnea, hearing loss, asthma, etc.- have found similarly low correlations between objective and subjective testing. For nasal septal deviation and CRS, the patient's subjective perception of disease severity has, at best, a very weak association with objective assessment of severity. Patient-based outcomes assessment remains important; these instruments apparently quantify an aspect of disease not detected by objective testing.

Endoscopic septoplasty

Endoscopic septoplasty is a minimally invasive technique that helps us to correct defornity of septum under excellent visualization. Lanza et al & Stammberger initially described the application of endoscopic technique for the correction of septal deformity in 1991. A retrospective study was carried out of all the cases that underwent endoscopic septoplasty at Dr. Shroff's Charity Eye hospital from March 1998 to March 2000. 78 consecutive septoplasty patients were identified in two years. Out of these 48 septoplasties (52%) were performed with endoscopic technique. A large percentage of cases 48(41%) were those where septoplasty was performed in conjunction with endoscopic dacro cysto rhinostomy. In 8 cases (16%) it was performed alone as a primary procedure, 4 deviations were broadly based deflections (12%), 10 of septal deformities were spurs (20%), in 4 cases more than one type septal deformities were encountered. Thus we feel that endoscopic septoplasty is a fast developing concept & gaining popularity with increasing trend towards sinus endoscopic surgeries. Furthermore in complex deformities, better correction is possible with the help of endoscope. Since we can clearly see the posterior deviations.