- Email: [email protected]
Pediatric septoplasty
Author’s Accepted Manuscript
image
Pediatric Septoplasty Sarah R. Akkina, Sanjay R. Parikh
www.elsevier.com/locate/bios
PII: DOI: Reference:
S1043-1810(18)30014-9 https://doi.org/10.1016/j.otot.2018.03.006 YOTOT810
To appear in: Operative Techniques in Otolaryngology - Head and Neck Surgery Cite this article as: Sarah R. Akkina and Sanjay R. Parikh, Pediatric Septoplasty, Operative Techniques in Otolaryngology - Head and Neck Surgery,doi:10.1016/j.otot.2018.03.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Pediatric Septoplasty Sarah R. Akkina, MD, MSc1; Sanjay R. Parikh, MD, FACS2ǂ 1
Resident, Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington 2
Professor, Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington and Seattle Children’s Hospital, Seattle, Washington Work performed at the Seattle Children’s Hospital, Seattle, Washington.
Disclosure statement The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Dr. Akkina has received support through the National Institutes of Health National Institute on Deafness and Other Communication Disorders T32 DC000018 Research Training Grant.
Keywords: pediatric septoplasty ǂ
Corresponding author: Sanjay R Parikh, MD, FACS Department of Otolaryngology-Head and Neck Surgery Seattle Children’s Hospital OA.9.220-Otolaryngology 4800 Sand Point Way NE Seattle, WA 98105 Email: [email protected]
ABSTRACT
While septoplasty is routinely performed in the adult population, concerns regarding nasal and facial growth have restricted use of this effective procedure in the pediatric population. As a growing number of studies have demonstrated the safety of this technique and its positive effect on quality of life outcomes, septoplasty is gaining greater acceptance as a central treatment for pediatric nasal obstruction. This article explores the controversies, indications, pre-operative evaluation, and techniques of pediatric septoplasty including closed and open approaches. It also describes post-operative care and possible complications of pediatric septoplasty. Introduction Nasal obstruction due to septal deviation is a common complaint in the pediatric and adult populations. However, while septoplasty has been a widely accepted and commonly performed procedure in adults, it is not routinely performed in children. This age restriction has mainly developed out of concern for the effects of surgery on craniofacial development 1,2. Concern was previously based on animal studies that demonstrated growth disturbance to the upper face after resection of the cartilaginous nasal septum 3. However, more recent anthropomorphic studies specifically examining facial growth after septoplasty in children have demonstrated no statistically significant difference in any of the anthropomorphic measurements assessed 4-6.
Unaddressed nasal obstruction secondary to septal deviation may be detrimental to children. Studies examining the effect of impairment of nasal breathing due to nasal obstruction on maxillofacial development have shown that children with obligate mouth breathing secondary to nasal septum deviation have facial and dental anomalies compared to nasal-breathing controls 7. This suggests that failing to perform pediatric septoplasty may be more harmful for children with nasal obstruction. In addition, pediatric septoplasty has been shown to improve short-term quality of life indicators, including the Nose Obstruction Symptom Evaluation (NOSE), Visual Analog Scale (VAS), and Sinus and Nasal Quality of Life Survey (SN-5), for those undergoing septoplasty due to significant nasal obstruction 8,9. Indications There are two main indications to perform septoplasty in the pediatric population: sleep apnea and quality of life. It is important to note that at least in adults, quality of life measurements after septoplasty have not been demonstrated to correlate well with the objective severity of the septal deviation 10. Although validation of quality of life scales have been obtained in adults, no pediatric corollary currently exists. Recent research has used scales including the NOSE, VAS, and SN-5 as mentioned above. Pre-operative Evaluation The pre-operative evaluation consists of assessing quality of life of the child as well as objective measures of obstruction. Quality of life indicators can be completed by either the parent or the children depending on the child’s age. Objective data can be assessed using polysomnography in patients with suspected sleep apnea. Objective flow dynamic
assessments of the airway may also be obtained through either acoustic rhinometry or head out plethysmography 11. Surgical Technique The following discussion of surgical technique is subdivided between a closed approach, an open approach, and an open approach with spreader grafts. For each approach, the patient is first placed in the supine position on the operative table. Following intubation, the endotracheal tube is secured to the chin at midline to ensure accurate assessment of facial symmetry. Lubricant eye ointment is placed bilaterally, after which each eyelid is closed and secured using a transparent dressing. The caudal septum and nasal structures are injected with a solution of 1% lidocaine with 1:100,000 epinephrine in a submucoperichondrial plane ideally resulting in hydrodissection. Two 0.5 x 3 inch cottonoid pledgets soaked with oxymetazoline are then placed in each nasal cavity. The operating room table is then rotated counter clockwise 120 degrees and the head of the operating table is elevated roughly 15 degrees to reduce venous congestion intraoperatively. Drapes are then placed, keeping the entire face in the surgical field. The pledgets are removed, and the following approaches are employed. Closed Approach This approach is appropriate for mid nose or posterior pathology. It requires adequate nostril size to allow appropriate room for movement of instrumentation. On the side ipsilateral to the septal deviation, a Killian or hemitransfixion incision is made. The hemitransfixion incision is preferred when the caudal septum is pathologically involved. A 15-blade scalpel is used to make the incision through the mucosa and perichondrium. Cartilage is gently scored with the 15 blade, and a Cottle periosteal elevator is
used to identify and enter the submucoperichondrial plane. The flap is extended in an anterior to posterior direction, using the Cottle speculum to increase exposure. The flap is raised using a sweeping motion of the Cottle elevator. When a spur is found, the flap is elevated first above and below. These tunnels are then connected over the deformity, and in this matter mucosal perforation is ideally avoided. The Cottle elevator is then used to incise through the caudal portion of the cartilage just anterior to the deformity. A similar mucoperichondrial flap is then raised on the contralateral side of the defect in an anterior to posterior fashion. The cartilage deformity is then excised using a combination of sharp excision and/or punch out with a Jansen-Middleton double-arm punch. If bony deformities are identified particularly along the maxillary crest, a 2 or 3 mm osteotome may be used to remove the defect. Care is made to preserve as much cartilage as possible, with a very minimal of 1cm or greater caudal and dorsal strut maintained throughout the procedure to prevent saddle nose deformity or tip ptosis. Once the deformity has been completely excised, bilateral mucoperichondrial flaps are reapproximated using a quilting suture of 4-0 chromic gut. Doyle splints covered in Bacitracin are then placed in bilateral nares. Splints are sutured to the septum with 3-0 Prolene. The oral cavity and nose are then suctioned and the patient is returned to the care of the anesthesia team for extubation and awakening.
Open Approach This approach is appropriate for anterior pathology. It is also preferred for patients with a small nostril size. For the pediatric population, the majority of cases will fall into this category in the authors’ experience. An inverted V incision is drawn at the narrowest point of the columella (Figure 1). The incision is made with a Weck knife and carried into a marginal incision with Converse scissors. These scissors are then used to dissect the soft tissue away from the lower lateral and upper lateral cartilages to expose the caudal aspect of the septum and nasal dorsum. The nasal skin is retracted with a caudal elevator (Figure 2). Bovie electrocautery is used to separate the medial crura at the midline and further expose the caudal end of the septum. The cartilage is gently scored with the Bovie cautery and a Cottle elevator is used to identify and raise mucoperichondrial flaps bilaterally. The flaps are continued down onto the floor of the nose bilaterally to expose the full extent of the quadrangular cartilage, maxillary crest, vomer and perpendicular plate of the ethmoid bones. Deformities of the septal cartilage are conservatively removed with a combination of Cottle elevator and D-knife. Fractures or twists of the cartilage may be identified and scored with a knife to allow for unravelling. The caudal edge of the septum is then affixed to the maxillary crest with 5-0 PDS. The quadrangular cartilage may or not be dislocated off the perpendicular plate of ethmoid as needed to position the cartilage in the midline. If bony deformities are identified, they are removed with an osteotome and Jansen-Middleton instruments. A quilting stitch is then placed through the septum using 4-0 chromic gut on a Keith needle. The columellar incision is then closed with 6-0 fast absorbing plain gut suture, and the marginal incisions are closed using 5-0 chromic suture bilaterally
(Figure 7). Absorbable sutures are preferred in young children. Doyle splints slathered in Bacitracin are then placed in bilateral nares and sutured to the septum with 3-0 Prolene. The oral cavity and nose are then suctioned and the patient is returned to the care of the anesthesia team for extubation and awakening. Open approach with spreader grafts
This approach is appropriate for nasal valve collapse and/or weak tip support resulting in nasal vestibular stenosis. The open approach is first begun, followed by separating the upper lateral cartilages away from the quadrangular cartilage in preparation for bilateral spreader grafts. These are obtained generally from the posterior inferior edge of the redundant portion of the septum (Figure 3), and carved on the surgical back table into 2mm sections in preparation for re-implantation (Figure 4). The spreader grafts are affixed between the upper lateral cartilages and the septum on either side with 5-0 polydioxanone (PDS) suture in simple interrupted fashion (Figure 5, 6). A single suture can then be placed to reapproximate the medial crura anterior to the quadrangular cartilage. A quilting suture with 4-0 chromic gut is used along the septum. The remainder of the procedure is similar to the open approach described above.
Post-operative Care
Typically, pediatric septoplasty is an outpatient procedures and patients are able to return home after surgery. Doyle splints are left for 7-10 days to ensure healing of the septal
mucosa, and are then removed at the first post-operative visit. Antibiotic prophylaxis is given while Doyle splints are in place.
Complications
The most common complications after septoplasty include epistaxis, septal perforation, incomplete correction of nasal obstruction with persistent symptoms, facial and upper dentition numbness, septal hematoma, saddle nose deformity, and tip ptosis. Rare complications also include septal cyst or abscess formation, cerebrospinal fluid rhinorrhea, unilateral blindness, tension pneumocephalus, and death 12,13.
Conclusions Nasal obstruction is an important problem in the pediatric population, with negative effects on quality of life and facial growth. Septoplasty is growing in acceptance as a primary means to address significant nasal obstruction due to septal deviation. The majority of cases in the author’s experience are undertaken via an open approach due to small nostril size. A cartilage-sparing approach is also a key procedural difference compared to the adult population in order to minimize effects on the growing craniofacial structure.
References
1. 2. 3.
4. 5.
6.
7.
8. 9.
10. 11.
12.
13.
Christophel JJ, Gross CW. Pediatric septoplasty. Otolaryngologic clinics of North America 2009; 42:287-294, ix. Pirsig W. Growth of the Deviated Septum and Its Influence on Midfacial Development. Facial Plast Surg 1992:224-232. Verwoerd CD, Verwoerd-Verhoef HL. Rhinosurgery in children: developmental and surgical aspects of the growing nose. GMS current topics in otorhinolaryngology, head and neck surgery 2010; 9:Doc05. Tasca I, Compadretti GC. Nasal growth after pediatric septoplasty at long-term followup. American journal of rhinology & allergy 2011; 25:e7-12. El-Hakim H, Crysdale WS, Abdollel M, Farkas LG. A study of anthropometric measures before and after external septoplasty in children: a preliminary study. Archives of otolaryngology--head & neck surgery 2001; 127:1362-1366. Walker PJ, Crysdale WS, Farkas LG. External septorhinoplasty in children: Outcome and effect on growth of septal excision and reimplantation. Archives of otolaryngology-head & neck surgery 1993; 119:984-989. D'Ascanio L, Lancione C, Pompa G, Rebuffini E, Mansi N, Manzini M. Craniofacial growth in children with nasal septum deviation: a cephalometric comparative study. International journal of pediatric otorhinolaryngology 2010; 74:1180-1183. Lee VS, Gold RM, Parikh SR. Short-term quality of life outcomes following pediatric septoplasty. Acta oto-laryngologica 2017; 137:293-296. Yilmaz MS, Guven M, Akidil O, Kayabasoglu G, Demir D, Mermer H. Does septoplasty improve the quality of life in children? International journal of pediatric otorhinolaryngology 2014; 78:1274-1276. Stewart MG, Smith TL. Objective versus subjective outcomes assessment in rhinology. American journal of rhinology 2005; 19:529-535. Can IH, Ceylan K, Bayiz U, Olmez A, Samim E. Acoustic rhinometry in the objective evaluation of childhood septoplasties. International journal of pediatric otorhinolaryngology 2005; 69:445-448. Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: techniques in septoplasty. Otolaryngologic clinics of North America 2009; 42:241-252, viii. Naraghi M, Ghazizadeh M. Tension pneumocephalus: a life-threatening complication of septoplasty and septorhinoplasty. B-ent 2012; 8:203-205.
Figure Legend
Figure 1. Demarcation of the inverted V incision Figure 2. Exposure of the caudal septum and lower cartilages, using caudal elevator for skin retraction Figure 3. Harvesting inferior cartilaginous septum with converse scissors for future spreader grafts Figure 4. Spreader grafts prepared from harvested septal cartilage Figure 5. Positioning of spreader grafts between upper lateral cartilages and septum Figure 6. Assessing position of spreader grafts Figure 7. Closure of columellar incision
image
Pediatric Septoplasty Sarah R. Akkina, Sanjay R. Parikh
www.elsevier.com/locate/bios
PII: DOI: Reference:
S1043-1810(18)30014-9 https://doi.org/10.1016/j.otot.2018.03.006 YOTOT810
To appear in: Operative Techniques in Otolaryngology - Head and Neck Surgery Cite this article as: Sarah R. Akkina and Sanjay R. Parikh, Pediatric Septoplasty, Operative Techniques in Otolaryngology - Head and Neck Surgery,doi:10.1016/j.otot.2018.03.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Pediatric Septoplasty Sarah R. Akkina, MD, MSc1; Sanjay R. Parikh, MD, FACS2ǂ 1
Resident, Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington 2
Professor, Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle, Washington and Seattle Children’s Hospital, Seattle, Washington Work performed at the Seattle Children’s Hospital, Seattle, Washington.
Disclosure statement The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Dr. Akkina has received support through the National Institutes of Health National Institute on Deafness and Other Communication Disorders T32 DC000018 Research Training Grant.
Keywords: pediatric septoplasty ǂ
Corresponding author: Sanjay R Parikh, MD, FACS Department of Otolaryngology-Head and Neck Surgery Seattle Children’s Hospital OA.9.220-Otolaryngology 4800 Sand Point Way NE Seattle, WA 98105 Email: [email protected]
ABSTRACT
While septoplasty is routinely performed in the adult population, concerns regarding nasal and facial growth have restricted use of this effective procedure in the pediatric population. As a growing number of studies have demonstrated the safety of this technique and its positive effect on quality of life outcomes, septoplasty is gaining greater acceptance as a central treatment for pediatric nasal obstruction. This article explores the controversies, indications, pre-operative evaluation, and techniques of pediatric septoplasty including closed and open approaches. It also describes post-operative care and possible complications of pediatric septoplasty. Introduction Nasal obstruction due to septal deviation is a common complaint in the pediatric and adult populations. However, while septoplasty has been a widely accepted and commonly performed procedure in adults, it is not routinely performed in children. This age restriction has mainly developed out of concern for the effects of surgery on craniofacial development 1,2. Concern was previously based on animal studies that demonstrated growth disturbance to the upper face after resection of the cartilaginous nasal septum 3. However, more recent anthropomorphic studies specifically examining facial growth after septoplasty in children have demonstrated no statistically significant difference in any of the anthropomorphic measurements assessed 4-6.
Unaddressed nasal obstruction secondary to septal deviation may be detrimental to children. Studies examining the effect of impairment of nasal breathing due to nasal obstruction on maxillofacial development have shown that children with obligate mouth breathing secondary to nasal septum deviation have facial and dental anomalies compared to nasal-breathing controls 7. This suggests that failing to perform pediatric septoplasty may be more harmful for children with nasal obstruction. In addition, pediatric septoplasty has been shown to improve short-term quality of life indicators, including the Nose Obstruction Symptom Evaluation (NOSE), Visual Analog Scale (VAS), and Sinus and Nasal Quality of Life Survey (SN-5), for those undergoing septoplasty due to significant nasal obstruction 8,9. Indications There are two main indications to perform septoplasty in the pediatric population: sleep apnea and quality of life. It is important to note that at least in adults, quality of life measurements after septoplasty have not been demonstrated to correlate well with the objective severity of the septal deviation 10. Although validation of quality of life scales have been obtained in adults, no pediatric corollary currently exists. Recent research has used scales including the NOSE, VAS, and SN-5 as mentioned above. Pre-operative Evaluation The pre-operative evaluation consists of assessing quality of life of the child as well as objective measures of obstruction. Quality of life indicators can be completed by either the parent or the children depending on the child’s age. Objective data can be assessed using polysomnography in patients with suspected sleep apnea. Objective flow dynamic
assessments of the airway may also be obtained through either acoustic rhinometry or head out plethysmography 11. Surgical Technique The following discussion of surgical technique is subdivided between a closed approach, an open approach, and an open approach with spreader grafts. For each approach, the patient is first placed in the supine position on the operative table. Following intubation, the endotracheal tube is secured to the chin at midline to ensure accurate assessment of facial symmetry. Lubricant eye ointment is placed bilaterally, after which each eyelid is closed and secured using a transparent dressing. The caudal septum and nasal structures are injected with a solution of 1% lidocaine with 1:100,000 epinephrine in a submucoperichondrial plane ideally resulting in hydrodissection. Two 0.5 x 3 inch cottonoid pledgets soaked with oxymetazoline are then placed in each nasal cavity. The operating room table is then rotated counter clockwise 120 degrees and the head of the operating table is elevated roughly 15 degrees to reduce venous congestion intraoperatively. Drapes are then placed, keeping the entire face in the surgical field. The pledgets are removed, and the following approaches are employed. Closed Approach This approach is appropriate for mid nose or posterior pathology. It requires adequate nostril size to allow appropriate room for movement of instrumentation. On the side ipsilateral to the septal deviation, a Killian or hemitransfixion incision is made. The hemitransfixion incision is preferred when the caudal septum is pathologically involved. A 15-blade scalpel is used to make the incision through the mucosa and perichondrium. Cartilage is gently scored with the 15 blade, and a Cottle periosteal elevator is
used to identify and enter the submucoperichondrial plane. The flap is extended in an anterior to posterior direction, using the Cottle speculum to increase exposure. The flap is raised using a sweeping motion of the Cottle elevator. When a spur is found, the flap is elevated first above and below. These tunnels are then connected over the deformity, and in this matter mucosal perforation is ideally avoided. The Cottle elevator is then used to incise through the caudal portion of the cartilage just anterior to the deformity. A similar mucoperichondrial flap is then raised on the contralateral side of the defect in an anterior to posterior fashion. The cartilage deformity is then excised using a combination of sharp excision and/or punch out with a Jansen-Middleton double-arm punch. If bony deformities are identified particularly along the maxillary crest, a 2 or 3 mm osteotome may be used to remove the defect. Care is made to preserve as much cartilage as possible, with a very minimal of 1cm or greater caudal and dorsal strut maintained throughout the procedure to prevent saddle nose deformity or tip ptosis. Once the deformity has been completely excised, bilateral mucoperichondrial flaps are reapproximated using a quilting suture of 4-0 chromic gut. Doyle splints covered in Bacitracin are then placed in bilateral nares. Splints are sutured to the septum with 3-0 Prolene. The oral cavity and nose are then suctioned and the patient is returned to the care of the anesthesia team for extubation and awakening.
Open Approach This approach is appropriate for anterior pathology. It is also preferred for patients with a small nostril size. For the pediatric population, the majority of cases will fall into this category in the authors’ experience. An inverted V incision is drawn at the narrowest point of the columella (Figure 1). The incision is made with a Weck knife and carried into a marginal incision with Converse scissors. These scissors are then used to dissect the soft tissue away from the lower lateral and upper lateral cartilages to expose the caudal aspect of the septum and nasal dorsum. The nasal skin is retracted with a caudal elevator (Figure 2). Bovie electrocautery is used to separate the medial crura at the midline and further expose the caudal end of the septum. The cartilage is gently scored with the Bovie cautery and a Cottle elevator is used to identify and raise mucoperichondrial flaps bilaterally. The flaps are continued down onto the floor of the nose bilaterally to expose the full extent of the quadrangular cartilage, maxillary crest, vomer and perpendicular plate of the ethmoid bones. Deformities of the septal cartilage are conservatively removed with a combination of Cottle elevator and D-knife. Fractures or twists of the cartilage may be identified and scored with a knife to allow for unravelling. The caudal edge of the septum is then affixed to the maxillary crest with 5-0 PDS. The quadrangular cartilage may or not be dislocated off the perpendicular plate of ethmoid as needed to position the cartilage in the midline. If bony deformities are identified, they are removed with an osteotome and Jansen-Middleton instruments. A quilting stitch is then placed through the septum using 4-0 chromic gut on a Keith needle. The columellar incision is then closed with 6-0 fast absorbing plain gut suture, and the marginal incisions are closed using 5-0 chromic suture bilaterally
(Figure 7). Absorbable sutures are preferred in young children. Doyle splints slathered in Bacitracin are then placed in bilateral nares and sutured to the septum with 3-0 Prolene. The oral cavity and nose are then suctioned and the patient is returned to the care of the anesthesia team for extubation and awakening. Open approach with spreader grafts
This approach is appropriate for nasal valve collapse and/or weak tip support resulting in nasal vestibular stenosis. The open approach is first begun, followed by separating the upper lateral cartilages away from the quadrangular cartilage in preparation for bilateral spreader grafts. These are obtained generally from the posterior inferior edge of the redundant portion of the septum (Figure 3), and carved on the surgical back table into 2mm sections in preparation for re-implantation (Figure 4). The spreader grafts are affixed between the upper lateral cartilages and the septum on either side with 5-0 polydioxanone (PDS) suture in simple interrupted fashion (Figure 5, 6). A single suture can then be placed to reapproximate the medial crura anterior to the quadrangular cartilage. A quilting suture with 4-0 chromic gut is used along the septum. The remainder of the procedure is similar to the open approach described above.
Post-operative Care
Typically, pediatric septoplasty is an outpatient procedures and patients are able to return home after surgery. Doyle splints are left for 7-10 days to ensure healing of the septal
mucosa, and are then removed at the first post-operative visit. Antibiotic prophylaxis is given while Doyle splints are in place.
Complications
The most common complications after septoplasty include epistaxis, septal perforation, incomplete correction of nasal obstruction with persistent symptoms, facial and upper dentition numbness, septal hematoma, saddle nose deformity, and tip ptosis. Rare complications also include septal cyst or abscess formation, cerebrospinal fluid rhinorrhea, unilateral blindness, tension pneumocephalus, and death 12,13.
Conclusions Nasal obstruction is an important problem in the pediatric population, with negative effects on quality of life and facial growth. Septoplasty is growing in acceptance as a primary means to address significant nasal obstruction due to septal deviation. The majority of cases in the author’s experience are undertaken via an open approach due to small nostril size. A cartilage-sparing approach is also a key procedural difference compared to the adult population in order to minimize effects on the growing craniofacial structure.
References
1. 2. 3.
4. 5.
6.
7.
8. 9.
10. 11.
12.
13.
Christophel JJ, Gross CW. Pediatric septoplasty. Otolaryngologic clinics of North America 2009; 42:287-294, ix. Pirsig W. Growth of the Deviated Septum and Its Influence on Midfacial Development. Facial Plast Surg 1992:224-232. Verwoerd CD, Verwoerd-Verhoef HL. Rhinosurgery in children: developmental and surgical aspects of the growing nose. GMS current topics in otorhinolaryngology, head and neck surgery 2010; 9:Doc05. Tasca I, Compadretti GC. Nasal growth after pediatric septoplasty at long-term followup. American journal of rhinology & allergy 2011; 25:e7-12. El-Hakim H, Crysdale WS, Abdollel M, Farkas LG. A study of anthropometric measures before and after external septoplasty in children: a preliminary study. Archives of otolaryngology--head & neck surgery 2001; 127:1362-1366. Walker PJ, Crysdale WS, Farkas LG. External septorhinoplasty in children: Outcome and effect on growth of septal excision and reimplantation. Archives of otolaryngology-head & neck surgery 1993; 119:984-989. D'Ascanio L, Lancione C, Pompa G, Rebuffini E, Mansi N, Manzini M. Craniofacial growth in children with nasal septum deviation: a cephalometric comparative study. International journal of pediatric otorhinolaryngology 2010; 74:1180-1183. Lee VS, Gold RM, Parikh SR. Short-term quality of life outcomes following pediatric septoplasty. Acta oto-laryngologica 2017; 137:293-296. Yilmaz MS, Guven M, Akidil O, Kayabasoglu G, Demir D, Mermer H. Does septoplasty improve the quality of life in children? International journal of pediatric otorhinolaryngology 2014; 78:1274-1276. Stewart MG, Smith TL. Objective versus subjective outcomes assessment in rhinology. American journal of rhinology 2005; 19:529-535. Can IH, Ceylan K, Bayiz U, Olmez A, Samim E. Acoustic rhinometry in the objective evaluation of childhood septoplasties. International journal of pediatric otorhinolaryngology 2005; 69:445-448. Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: techniques in septoplasty. Otolaryngologic clinics of North America 2009; 42:241-252, viii. Naraghi M, Ghazizadeh M. Tension pneumocephalus: a life-threatening complication of septoplasty and septorhinoplasty. B-ent 2012; 8:203-205.
Figure Legend
Figure 1. Demarcation of the inverted V incision Figure 2. Exposure of the caudal septum and lower cartilages, using caudal elevator for skin retraction Figure 3. Harvesting inferior cartilaginous septum with converse scissors for future spreader grafts Figure 4. Spreader grafts prepared from harvested septal cartilage Figure 5. Positioning of spreader grafts between upper lateral cartilages and septum Figure 6. Assessing position of spreader grafts Figure 7. Closure of columellar incision