- Email: [email protected]
A new “J septoplasty” technique for correction of mild caudal septal deviation
G Model
ANL-2610; No. of Pages 5 Auris Nasus Larynx xxx (2019) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
A new “J septoplasty” technique for correction of mild caudal septal deviation$ Jiro Iimura a,b,*, Takeshi Miyawaki c, Shun Kikuchi b, Shinya Tsumiyama c, Eri Mori b, Tsuneya Nakajima a, Hiromi Kojima b, Nobuyoshi Otori b a
Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, Japan Department of Otorhinolaryngology, The Jikei University School of Medicine, Japan c Department of Plastic surgery, The Jikei University School of Medicine, Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 November 2018 Accepted 25 April 2019 Available online xxx
Objective: A major drawback of the Killian incision is its inability to access the caudal septum and correct caudal septal deviation. Open and hemitransfixion septorhinoplasty are considered necessary in such cases. We developed a new septoplasty method that can be successfully applied in patients with mild caudal septal deviation. In this study, we evaluated the outcome of this technique. Methods: We prospectively collected data of 16 patients with mild caudal septal deviation who underwent endoscopic septoplasty between November 2015 and October 2017. A modified Killian incision was made on the concave side of the septum. The central part of the cartilage was preserved, and excess cartilage was resected; the central part of the cartilage was sutured to the caudal cartilage. Results: Postoperatively, the ratio of the area of the convex side to that of the concave side in the anterior portion of the nasal cavity was significantly improved, as revealed on CT analysis (p < 0.001). Nasal obstruction was significantly reduced or eliminated in all patients (p < 0.001). Conclusion: The J septoplasty method for the correction of mild caudal septal deviation is easy to perform through a modified Killian incision, and seems to be useful in selected cases. © 2019 Published by Elsevier B.V.
Keywords: Septoplasty Caudal septal deviation Suture technique
1. Introduction Septoplasty is a surgical technique used to treat nasal obstruction caused by deviation of the nasal septum, and both the extent of correction and difficulty of the procedure depend on the extent of the septal deformation. Killian incision [1] has been the most widely used technique for septoplasty. However,
$
Institutional review board statement, The Jikei University Hospital Ethics Committee Review: 25-073, 7208. * Corresponding author at: Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan E-mail address: [email protected] (J. Iimura).
recent reports have indicated that this method does not always sufficiently resolve the nasal obstruction postoperatively [2]. In this situation, the recommended approach is either hemitransfixion [3–5] or open septorhinoplasty. Using the hemitransfixion approach, an incision is made on the caudal end of the cartilage. This technique includes cutting and suturing [4], separating from the anterior nasal spine, and caudal septal batten grafting [3,5]. Open septorhinoplasty requires an external incision that some patients prefer not to receive; hence, it is not widely performed by Japanese rhinologists [6]. Thus, a simpler approach that does not entail an external incision would be beneficial for such patients. Furthermore, in some cases, the invasiveness of hemitransfixion and open septorhinoplasty is disproportional to the
https://doi.org/10.1016/j.anl.2019.04.009 0385-8146/© 2019 Published by Elsevier B.V.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
G Model
ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx
2
extent of septal deformation, and neither approach seems to be necessary in patients with mild deviation of the caudal part of the septum. We have developed a new operative technique called “J septoplasty”, which can be used successfully in patients with mild caudal septal deviation. The J septoplasty can be performed easily through a modified Killian incision but incorporates a new type of septal trimming and suturing. The purpose of this research was to demonstrate the details of this technique and evaluate its postoperative outcomes.
2. Patients and methods The study protocol was approved by the Review Board of the Jikei University Hospital Ethics Committee (approval number 25-073, 7208). All study participants provided informed consent for participation in the study. We prospectively collected data for 16 patients who underwent endoscopic septoplasty at the Jikei University Hospital between November 2015 and October 2017. All patients had mild deviation of the caudal septum that was not accompanied by any external nasal deformity. The mild caudal deviation is generalized C-shaped caudal septal deviation with a straight caudal end, not complicated by angulation or dislocation of the caudal septum. Endoscopic evaluation was performed before and after surgery using a 0-degree endoscope.
All procedures were performed under general anesthesia. First, 1% lidocaine with 1:200,000 epinephrine was injected into the septum. A modified Killian incision (approximately 5 mm cephalad from the caudal end of the septal cartilage) was made on the concave side of the nasal septum, and the mucoperiosteal flap was endoscopically elevated. Next, the perpendicular plate of the ethmoid bone and vomer were removed. Special care was taken to preserve the dorsal part of the L-strut. The cartilage incision was performed 10–15 mm cephalad from the caudal region of the septum. The caudal cartilage at its osseo-cartilaginous junction with the nasal crest was kept intact. The central part of the cartilage was also preserved (Fig. 1.a1, b1, c1). Via the cartilage incision, the central part was straightened after releasing the tension caused by the septal deviation. After the incision, a part of the remaining cartilage overlapped at its cephalad region with the caudal edge of the incised “free” edge (Fig. 1.a2, b2, c2). The free overlapping edge of the central part of the cartilage was then excised and the edges of the nasal crest was also reduced (Fig. 1.a3, b3, c3). Next, to further flatten the remaining cartilage, an additional excision was made in the central part of the cartilage edge (Fig. 1.a4, b4, c4). Finally, the remaining cartilage was sutured to the incised edge using more than three 5-0 PDS1 II sutures (Ethicon Inc, Somerville, NJ, USA; Fig. 1.a5, b5, c5). In cases with cephalic-caudal deviation of the septal cartilage, the deformity was corrected using cartilage flap
Fig. 1. a1–5: Schematic diagrams. b1–5: Horizontal CT scan images with imaginary shape of septal cartilage and ethomoidal perpendicular plate at each step of the surgical procedure. c1–5: Endoscopic views. Steps of the surgical procedure: a1, b1, c1: Cartilage incision. a2, b2, c2: The excessive regions of the central part of the cartilage became straight after the incision and overlap the caudal edge. a3, b3, c3: After excision of excessive central overlapping regions together with fragments of crista and spine, the remaining central part edge closely fits to the edge of the L-strut. a4, b4, c4: Additional excision on the central part edge to obtain post-suturing flattening of the corrected septum. a5, b5, c5: Final suturing of the central and caudal edges of the cartilage straightens the septum.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
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ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx
trimming and suturing techniques; batten grafting was necessary to strengthen the corrected septal tissue in patients with thin and weak cartilage. Computed tomography (CT) was used to objectively assess the postoperative outcome. CT scans were obtained in all patients before surgery and at 3 months postoperatively. Transverse cross-sectional CT images acquired as 3-mm-thick slices in the axial plane were evaluated. In each patient, the area extending from the anterior portion of the nasal cavity to the anterior edge of the frontal process of the maxilla was assessed using CT. The area was measured using the Image J software (National Institutes of Health, Bethesda, MD, USA; Fig. 2). Finally, the ratio of the area on the convex side to that on the concave side was calculated in each patient. All statistical analyses were performed using SPSS Statistics 19 for Windows (IBM Corp., Armonk, NY, USA). The preoperative and postoperative ratios were compared using the Wilcoxon signedrank test. A difference of 5% was considered statistically significant. 3. Results In all patients, septoplasty was performed with resection of the inferior turbinate mucosa. Additional endoscopic sinus surgery was performed in 6 patients. Fig. 3 shows the typical pre- and post-operative intranasal views on CT for one patient. Batten grafts were used in 2 patients to strengthen the weak caudal regions of the cartilage. CT analysis showed that the ratio of the convex to the concave area in the anterior portion of the nasal cavity was significantly higher postoperatively (p < 0.001; Fig. 4). All 16 patients were asked to rate the severity of their symptoms on a 7-point scale preoperatively and postoperatively (Table 1). Nasal obstruction was significantly reduced or eliminated in all patients (p < 0.001). The mean nasal symptom score decreased from 4.56 preoperatively to 1.75 postoperatively (Table 2). None of the patients showed postoperative complications, such
3
as saddle nose deformity, septal perforation, hematoma, infection, or nasal bleeding, at their 3-, 6-, and 12-month follow-up in the outpatient clinic. 4. Discussion Killian incision is the most widely used standard septoplasty technique in Japan. This incision is often made 10–15 mm cephalad from the caudal border of the septum. It has been shown that more extensive excisions of the cartilage and bone produce better correction of the deformity in patients with septal deviation. However, excessive removal of the septal cartilage and/or nasal bone may weaken the structural elements responsible for the external shape of the nose and lead to the development of saddle nose or under-rotated (hanging) nose deformities [7,8]. Hence, techniques aiming at preservation of the nasal septal cartilage (cartilage-preservation method) and hard tissues not directly related to the formation of septal deviation [9] have been recommended in recent years. Caudal septal deviation cannot be completely treated with the Killian incision, and much effort have been made to develop a surgical procedure that can correct this septal deformity. The external incision technique has been recommended; however, in Japan, most patients refuse an external incision for esthetic reasons. Therefore, this procedure is not widely performed by Japanese rhinologists. We developed a J septoplasty method for correction of caudal septal deviation that includes a novel trimming and suturing technique. The primary indication for J septoplasty is mild caudal deviation. Other rhinologists originally performed endonasal septoplasty with a batten graft via a hemitransfixion approach for the same indication, i.e., mild caudal septal deviation [5,9]. That technique was adapted to correct mild septal deviation not complicated by angulation or dislocation of the caudal septum. Our approach is less invasive and easier to perform. Open septorhinoplasty and hemitransfixion approaches have been recommended for patients with severe
Fig. 2. a1–5: preoperative, b1–5: postoperative CT images. The a1–5 and the b1–5 are pre- and postoperative cross-sectional CT images of the same patient. The dotted lines are convex areas. The solid lines are concave areas. Pre- and postoperative areas frontal to the anterior edge of the frontal process were measured on CT images.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
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ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx
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Fig. 3. An example case. a1–3: Preoperative images showing mild caudal septal deviation towards the right side. b1–3: Postoperative images showing correction of the convex region of the septum following “J septoplasty”.
septal deviation complicated by dislocation of the septal cartilage from the anterior nasal spine. Using these methods, surgical detachment of the cartilage from the anterior nasal spine releases the tension produced by the deviated septal region [10]; then, the excessive cartilage is removed, and the remaining part is fixed at its central region [9,11]. Development of septal deviation is closely associated with growth and maturation of the nasal cartilage within the bony framework of the nose. Cartilage grows more rapidly than the bone, so the excess cartilage eventually overgrows the bony framework and causes an imbalance that manifests as septal deviation. The excess cartilage should be removed to correct the deviation effectively. Using our technique, after incision of the cartilage, the central cephalad cartilage overlaps the caudal incised edge (Fig. 1.a2, b2, c2). Excision of the overlapping regions of the cartilage to achieve a close fit with the L-strut edge (Fig. 1.a3, b3, c3) would not be sufficient to correct the deviation because bending of both the remaining cartilage and L-strut would remain almost intact. Excision of the excessive margin on the incised edge of the central part of the cartilage
Fig. 4. Changes of the calculated ratios on of the area on the convex side to that on the concave side in the anterior portion of the nasal cavity before and after surgery. In all patients, the ratios significantly increased (p < 0.001) post-operatively indicating effective straightening of the nasal septum.
Table 1 Subjective symptoms score (7-point scale). Symptom
None
Nasal obstruction
0 &
Mild 1 &
2 &
Moderate 3 &
4 &
Severe 5 &
6 &
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
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ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx Table 2 Summary of pre- and postoperative subjective symptoms outcomes.
Nasal obstruction
Preoperative
Postoperative
p value
4.56
1.75
<0.001
(Fig. 1.a4, b4, c4) and then suturing the edges together would eventually “stretch” and flatten the septum (Fig. 1.a5, b5, c5). The novel aspect of the J septoplasty is the reduction of excessive cartilage in the middle region and the pulling together of the central and caudal parts of the cartilage to indirectly straighten the deviated dorsal region (L-strut) with a pulling force. Given that most of the septal cartilage is preserved, the supportive function of the nasal septum overall is not compromised. However, if the excision of the central cartilage is excessive, attaching and suturing the edges together exert too strong a pulling force on the dorsal and cephalad regions in the caudal direction and may cause unnecessary strain on the keystone area, eventually leading to development of saddle nose deformity. Therefore, adaptation of this method is feasible only in mild caudal deviation cases. At present, there are no definitive guidelines regarding the most appropriate septoplasty method and selection of the most appropriate technique is often based on CT and endoscopic findings and on visual and tactile observations. This lack of guidelines becomes particularly problematic in patients with caudal septal deviation because preoperative diagnosis often implies that the Killian incision would be satisfactory whereas postoperatively the deviation is often not adequately corrected and nasal obstruction does not improve. In such patients, a change in the operative technique is often necessary and our J septoplasty seems to be the method of choice. It is technically easier to perform than hemitransfixion and open septorhinoplasty and the risk of postoperative deformity can be prevented by preserving the L-strut. In all patients who have undergone J septoplasty in our series, there were no postoperative complications and there was significant improvement in nasal obstruction.
5
5. Conclusion An ideal septoplasty should be minimally invasive and improve nasal obstruction; moreover, it should not be complicated by surgery-related nasal deformities. Our J septoplasty method for the correction of mild caudal septal deviation can be easily performed through a modified Killian incision and may be a useful technique in selected cases. Conflicts of interest All authors have no conflicts of interest to declare. References [1] Killian G. Submucosal window resection of the nasal septum. Arch Laryngol Rhinol 1904;16:362–87 [In German]. [2] Jang YJ. Correction of the deviated nose. In: Jang YJ, Park CH, editors. Practical septoplasty. An Asian perspective. Seoul, South Korea: Koonja Publishing Inc.; 2007. p. 239–73. [3] Wee JH, Lee J-E, Cho S-W, Jin HR. Septal batten graft to correct cartilaginous deformities in endonasal septoplasty batten graft to correct cartilaginous deformities. Arch Otolaryngol Head Neck Surg 2012;138:457–61. [4] Jang YJ, Yeo N-K, Wang JH. Cutting and suture technique of the caudal septal cartilage for the management of caudal septal deviation. Arch Otolaryngol Head Neck Surg 2009;135:1256–60. [5] Kim JH, Kim DV, Jang YJ. Outcomes after endonasal septoplasty using caudal septal batten grafting. Am J Rhinol Allergy 2011;25. e166–e70. [6] Nakayama T, Okushi T, Yamakawa S, Kuboki A, Haruna S. Endoscopic single-handed septoplasty with batten graft for caudal septum deviation. Auris Nasus Larynx 2014;41:441–5. [7] Toriumi DM, Becker DG. Rhinoplasty dissection manual. Philadelphia, PA: Lippincott Williams Wilkins; 1999. p. 31–5. [8] Park CH. Septoplasty for rhinoplasty. In: Jang YJ, Park CH, editors. Practical septoplasty. An Asian perspective. Seoul, South Korea: Koonja Publishing Inc.; 2007. p. 95–124. [9] Jang YJ. Septoplasty. In: Jang YJ, editor. Rhinoplasty and septoplasty. Seoul, South Korea: Koonja Publishing Inc.; 2014. p. 75–92. [10] Gunter JP. Management of the deviated nose: the importance of septal reconstruction. Clin Plast Surg 1988;15:43–55. [11] Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast Reconstr Surg 1999;104:2203–9.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
ANL-2610; No. of Pages 5 Auris Nasus Larynx xxx (2019) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
A new “J septoplasty” technique for correction of mild caudal septal deviation$ Jiro Iimura a,b,*, Takeshi Miyawaki c, Shun Kikuchi b, Shinya Tsumiyama c, Eri Mori b, Tsuneya Nakajima a, Hiromi Kojima b, Nobuyoshi Otori b a
Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, Japan Department of Otorhinolaryngology, The Jikei University School of Medicine, Japan c Department of Plastic surgery, The Jikei University School of Medicine, Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 November 2018 Accepted 25 April 2019 Available online xxx
Objective: A major drawback of the Killian incision is its inability to access the caudal septum and correct caudal septal deviation. Open and hemitransfixion septorhinoplasty are considered necessary in such cases. We developed a new septoplasty method that can be successfully applied in patients with mild caudal septal deviation. In this study, we evaluated the outcome of this technique. Methods: We prospectively collected data of 16 patients with mild caudal septal deviation who underwent endoscopic septoplasty between November 2015 and October 2017. A modified Killian incision was made on the concave side of the septum. The central part of the cartilage was preserved, and excess cartilage was resected; the central part of the cartilage was sutured to the caudal cartilage. Results: Postoperatively, the ratio of the area of the convex side to that of the concave side in the anterior portion of the nasal cavity was significantly improved, as revealed on CT analysis (p < 0.001). Nasal obstruction was significantly reduced or eliminated in all patients (p < 0.001). Conclusion: The J septoplasty method for the correction of mild caudal septal deviation is easy to perform through a modified Killian incision, and seems to be useful in selected cases. © 2019 Published by Elsevier B.V.
Keywords: Septoplasty Caudal septal deviation Suture technique
1. Introduction Septoplasty is a surgical technique used to treat nasal obstruction caused by deviation of the nasal septum, and both the extent of correction and difficulty of the procedure depend on the extent of the septal deformation. Killian incision [1] has been the most widely used technique for septoplasty. However,
$
Institutional review board statement, The Jikei University Hospital Ethics Committee Review: 25-073, 7208. * Corresponding author at: Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan E-mail address: [email protected] (J. Iimura).
recent reports have indicated that this method does not always sufficiently resolve the nasal obstruction postoperatively [2]. In this situation, the recommended approach is either hemitransfixion [3–5] or open septorhinoplasty. Using the hemitransfixion approach, an incision is made on the caudal end of the cartilage. This technique includes cutting and suturing [4], separating from the anterior nasal spine, and caudal septal batten grafting [3,5]. Open septorhinoplasty requires an external incision that some patients prefer not to receive; hence, it is not widely performed by Japanese rhinologists [6]. Thus, a simpler approach that does not entail an external incision would be beneficial for such patients. Furthermore, in some cases, the invasiveness of hemitransfixion and open septorhinoplasty is disproportional to the
https://doi.org/10.1016/j.anl.2019.04.009 0385-8146/© 2019 Published by Elsevier B.V.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
G Model
ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx
2
extent of septal deformation, and neither approach seems to be necessary in patients with mild deviation of the caudal part of the septum. We have developed a new operative technique called “J septoplasty”, which can be used successfully in patients with mild caudal septal deviation. The J septoplasty can be performed easily through a modified Killian incision but incorporates a new type of septal trimming and suturing. The purpose of this research was to demonstrate the details of this technique and evaluate its postoperative outcomes.
2. Patients and methods The study protocol was approved by the Review Board of the Jikei University Hospital Ethics Committee (approval number 25-073, 7208). All study participants provided informed consent for participation in the study. We prospectively collected data for 16 patients who underwent endoscopic septoplasty at the Jikei University Hospital between November 2015 and October 2017. All patients had mild deviation of the caudal septum that was not accompanied by any external nasal deformity. The mild caudal deviation is generalized C-shaped caudal septal deviation with a straight caudal end, not complicated by angulation or dislocation of the caudal septum. Endoscopic evaluation was performed before and after surgery using a 0-degree endoscope.
All procedures were performed under general anesthesia. First, 1% lidocaine with 1:200,000 epinephrine was injected into the septum. A modified Killian incision (approximately 5 mm cephalad from the caudal end of the septal cartilage) was made on the concave side of the nasal septum, and the mucoperiosteal flap was endoscopically elevated. Next, the perpendicular plate of the ethmoid bone and vomer were removed. Special care was taken to preserve the dorsal part of the L-strut. The cartilage incision was performed 10–15 mm cephalad from the caudal region of the septum. The caudal cartilage at its osseo-cartilaginous junction with the nasal crest was kept intact. The central part of the cartilage was also preserved (Fig. 1.a1, b1, c1). Via the cartilage incision, the central part was straightened after releasing the tension caused by the septal deviation. After the incision, a part of the remaining cartilage overlapped at its cephalad region with the caudal edge of the incised “free” edge (Fig. 1.a2, b2, c2). The free overlapping edge of the central part of the cartilage was then excised and the edges of the nasal crest was also reduced (Fig. 1.a3, b3, c3). Next, to further flatten the remaining cartilage, an additional excision was made in the central part of the cartilage edge (Fig. 1.a4, b4, c4). Finally, the remaining cartilage was sutured to the incised edge using more than three 5-0 PDS1 II sutures (Ethicon Inc, Somerville, NJ, USA; Fig. 1.a5, b5, c5). In cases with cephalic-caudal deviation of the septal cartilage, the deformity was corrected using cartilage flap
Fig. 1. a1–5: Schematic diagrams. b1–5: Horizontal CT scan images with imaginary shape of septal cartilage and ethomoidal perpendicular plate at each step of the surgical procedure. c1–5: Endoscopic views. Steps of the surgical procedure: a1, b1, c1: Cartilage incision. a2, b2, c2: The excessive regions of the central part of the cartilage became straight after the incision and overlap the caudal edge. a3, b3, c3: After excision of excessive central overlapping regions together with fragments of crista and spine, the remaining central part edge closely fits to the edge of the L-strut. a4, b4, c4: Additional excision on the central part edge to obtain post-suturing flattening of the corrected septum. a5, b5, c5: Final suturing of the central and caudal edges of the cartilage straightens the septum.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
G Model
ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx
trimming and suturing techniques; batten grafting was necessary to strengthen the corrected septal tissue in patients with thin and weak cartilage. Computed tomography (CT) was used to objectively assess the postoperative outcome. CT scans were obtained in all patients before surgery and at 3 months postoperatively. Transverse cross-sectional CT images acquired as 3-mm-thick slices in the axial plane were evaluated. In each patient, the area extending from the anterior portion of the nasal cavity to the anterior edge of the frontal process of the maxilla was assessed using CT. The area was measured using the Image J software (National Institutes of Health, Bethesda, MD, USA; Fig. 2). Finally, the ratio of the area on the convex side to that on the concave side was calculated in each patient. All statistical analyses were performed using SPSS Statistics 19 for Windows (IBM Corp., Armonk, NY, USA). The preoperative and postoperative ratios were compared using the Wilcoxon signedrank test. A difference of 5% was considered statistically significant. 3. Results In all patients, septoplasty was performed with resection of the inferior turbinate mucosa. Additional endoscopic sinus surgery was performed in 6 patients. Fig. 3 shows the typical pre- and post-operative intranasal views on CT for one patient. Batten grafts were used in 2 patients to strengthen the weak caudal regions of the cartilage. CT analysis showed that the ratio of the convex to the concave area in the anterior portion of the nasal cavity was significantly higher postoperatively (p < 0.001; Fig. 4). All 16 patients were asked to rate the severity of their symptoms on a 7-point scale preoperatively and postoperatively (Table 1). Nasal obstruction was significantly reduced or eliminated in all patients (p < 0.001). The mean nasal symptom score decreased from 4.56 preoperatively to 1.75 postoperatively (Table 2). None of the patients showed postoperative complications, such
3
as saddle nose deformity, septal perforation, hematoma, infection, or nasal bleeding, at their 3-, 6-, and 12-month follow-up in the outpatient clinic. 4. Discussion Killian incision is the most widely used standard septoplasty technique in Japan. This incision is often made 10–15 mm cephalad from the caudal border of the septum. It has been shown that more extensive excisions of the cartilage and bone produce better correction of the deformity in patients with septal deviation. However, excessive removal of the septal cartilage and/or nasal bone may weaken the structural elements responsible for the external shape of the nose and lead to the development of saddle nose or under-rotated (hanging) nose deformities [7,8]. Hence, techniques aiming at preservation of the nasal septal cartilage (cartilage-preservation method) and hard tissues not directly related to the formation of septal deviation [9] have been recommended in recent years. Caudal septal deviation cannot be completely treated with the Killian incision, and much effort have been made to develop a surgical procedure that can correct this septal deformity. The external incision technique has been recommended; however, in Japan, most patients refuse an external incision for esthetic reasons. Therefore, this procedure is not widely performed by Japanese rhinologists. We developed a J septoplasty method for correction of caudal septal deviation that includes a novel trimming and suturing technique. The primary indication for J septoplasty is mild caudal deviation. Other rhinologists originally performed endonasal septoplasty with a batten graft via a hemitransfixion approach for the same indication, i.e., mild caudal septal deviation [5,9]. That technique was adapted to correct mild septal deviation not complicated by angulation or dislocation of the caudal septum. Our approach is less invasive and easier to perform. Open septorhinoplasty and hemitransfixion approaches have been recommended for patients with severe
Fig. 2. a1–5: preoperative, b1–5: postoperative CT images. The a1–5 and the b1–5 are pre- and postoperative cross-sectional CT images of the same patient. The dotted lines are convex areas. The solid lines are concave areas. Pre- and postoperative areas frontal to the anterior edge of the frontal process were measured on CT images.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
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ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx
4
Fig. 3. An example case. a1–3: Preoperative images showing mild caudal septal deviation towards the right side. b1–3: Postoperative images showing correction of the convex region of the septum following “J septoplasty”.
septal deviation complicated by dislocation of the septal cartilage from the anterior nasal spine. Using these methods, surgical detachment of the cartilage from the anterior nasal spine releases the tension produced by the deviated septal region [10]; then, the excessive cartilage is removed, and the remaining part is fixed at its central region [9,11]. Development of septal deviation is closely associated with growth and maturation of the nasal cartilage within the bony framework of the nose. Cartilage grows more rapidly than the bone, so the excess cartilage eventually overgrows the bony framework and causes an imbalance that manifests as septal deviation. The excess cartilage should be removed to correct the deviation effectively. Using our technique, after incision of the cartilage, the central cephalad cartilage overlaps the caudal incised edge (Fig. 1.a2, b2, c2). Excision of the overlapping regions of the cartilage to achieve a close fit with the L-strut edge (Fig. 1.a3, b3, c3) would not be sufficient to correct the deviation because bending of both the remaining cartilage and L-strut would remain almost intact. Excision of the excessive margin on the incised edge of the central part of the cartilage
Fig. 4. Changes of the calculated ratios on of the area on the convex side to that on the concave side in the anterior portion of the nasal cavity before and after surgery. In all patients, the ratios significantly increased (p < 0.001) post-operatively indicating effective straightening of the nasal septum.
Table 1 Subjective symptoms score (7-point scale). Symptom
None
Nasal obstruction
0 &
Mild 1 &
2 &
Moderate 3 &
4 &
Severe 5 &
6 &
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009
G Model
ANL-2610; No. of Pages 5 J. Iimura et al. / Auris Nasus Larynx xxx (2019) xxx–xxx Table 2 Summary of pre- and postoperative subjective symptoms outcomes.
Nasal obstruction
Preoperative
Postoperative
p value
4.56
1.75
<0.001
(Fig. 1.a4, b4, c4) and then suturing the edges together would eventually “stretch” and flatten the septum (Fig. 1.a5, b5, c5). The novel aspect of the J septoplasty is the reduction of excessive cartilage in the middle region and the pulling together of the central and caudal parts of the cartilage to indirectly straighten the deviated dorsal region (L-strut) with a pulling force. Given that most of the septal cartilage is preserved, the supportive function of the nasal septum overall is not compromised. However, if the excision of the central cartilage is excessive, attaching and suturing the edges together exert too strong a pulling force on the dorsal and cephalad regions in the caudal direction and may cause unnecessary strain on the keystone area, eventually leading to development of saddle nose deformity. Therefore, adaptation of this method is feasible only in mild caudal deviation cases. At present, there are no definitive guidelines regarding the most appropriate septoplasty method and selection of the most appropriate technique is often based on CT and endoscopic findings and on visual and tactile observations. This lack of guidelines becomes particularly problematic in patients with caudal septal deviation because preoperative diagnosis often implies that the Killian incision would be satisfactory whereas postoperatively the deviation is often not adequately corrected and nasal obstruction does not improve. In such patients, a change in the operative technique is often necessary and our J septoplasty seems to be the method of choice. It is technically easier to perform than hemitransfixion and open septorhinoplasty and the risk of postoperative deformity can be prevented by preserving the L-strut. In all patients who have undergone J septoplasty in our series, there were no postoperative complications and there was significant improvement in nasal obstruction.
5
5. Conclusion An ideal septoplasty should be minimally invasive and improve nasal obstruction; moreover, it should not be complicated by surgery-related nasal deformities. Our J septoplasty method for the correction of mild caudal septal deviation can be easily performed through a modified Killian incision and may be a useful technique in selected cases. Conflicts of interest All authors have no conflicts of interest to declare. References [1] Killian G. Submucosal window resection of the nasal septum. Arch Laryngol Rhinol 1904;16:362–87 [In German]. [2] Jang YJ. Correction of the deviated nose. In: Jang YJ, Park CH, editors. Practical septoplasty. An Asian perspective. Seoul, South Korea: Koonja Publishing Inc.; 2007. p. 239–73. [3] Wee JH, Lee J-E, Cho S-W, Jin HR. Septal batten graft to correct cartilaginous deformities in endonasal septoplasty batten graft to correct cartilaginous deformities. Arch Otolaryngol Head Neck Surg 2012;138:457–61. [4] Jang YJ, Yeo N-K, Wang JH. Cutting and suture technique of the caudal septal cartilage for the management of caudal septal deviation. Arch Otolaryngol Head Neck Surg 2009;135:1256–60. [5] Kim JH, Kim DV, Jang YJ. Outcomes after endonasal septoplasty using caudal septal batten grafting. Am J Rhinol Allergy 2011;25. e166–e70. [6] Nakayama T, Okushi T, Yamakawa S, Kuboki A, Haruna S. Endoscopic single-handed septoplasty with batten graft for caudal septum deviation. Auris Nasus Larynx 2014;41:441–5. [7] Toriumi DM, Becker DG. Rhinoplasty dissection manual. Philadelphia, PA: Lippincott Williams Wilkins; 1999. p. 31–5. [8] Park CH. Septoplasty for rhinoplasty. In: Jang YJ, Park CH, editors. Practical septoplasty. An Asian perspective. Seoul, South Korea: Koonja Publishing Inc.; 2007. p. 95–124. [9] Jang YJ. Septoplasty. In: Jang YJ, editor. Rhinoplasty and septoplasty. Seoul, South Korea: Koonja Publishing Inc.; 2014. p. 75–92. [10] Gunter JP. Management of the deviated nose: the importance of septal reconstruction. Clin Plast Surg 1988;15:43–55. [11] Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast Reconstr Surg 1999;104:2203–9.
Please cite this article in press as: Iimura J, et al. A new “J septoplasty” technique for correction of mild caudal septal deviation. Auris Nasus Larynx (2019), https://doi.org/10.1016/j.anl.2019.04.009