How to Resolve the Caudal Septal Deviation?: Clinical Outcomes

The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. How to Resolve the Caudal Septal Deviation?: Clinical Outcomes After Septoplasty With Bony Batten Grafting Yong S. Chung, MD; Jeong-Hun Seol, MD; Jee-Min Choi, MD; Dong-Hyuk Shin, MD; Yong W. Kim, MD; Jae H. Cho, MD, PhD; Jin K. Kim, MD, PhD Objectives/Hypothesis: Caudal septal deviation interrupts normal nasal breathing, due to the narrowing of the external valve area and nasal valve angle. In this study, we found a different approach for correction of caudal septal deviation with no associated deformity of the external nose. Study Design: Individual case control study. Methods: The 39 patients completed questionnaires by interviews postoperatively for assessment of nasal obstruction. In addition, patients assessed the severity of their nasal symptoms (i.e., mouth breathing, mouth dryness, hyposmia, rhinorrhea, epistaxis, snoring, postnasal drip, and headache) preoperatively and postoperatively using a visual analog scale (VAS). Improvement in the treatment of nasal obstruction using a VAS and a questionnaire for subjective satisfaction were evaluated 3 months after septoplasty. To evaluate outcomes objectively, endoscopic photographs of the nasal cavity and acoustic rhinometry before and after surgery were evaluated. For comparison between preoperative and postoperative status, the Wilcoxon signed ranks test was used. Results: Patients reported a significant decrease in the VAS severity of all nasal symptoms. The minimal cross-sectional area (MCA1) of the convex side after vascular constriction using acoustic rhinometry showed significant widening. Patients were divided into a turbinoplasty group and a nonturbinoplasty group, and the turbinoplasty group showed a significant increase in both the convex side and concave side in MCA1 and in the convex side in the anterior portion of the inferior turbinate. Conclusions: Endonasal septoplasty using bony batten grafting for caudal septal deviation resulted in an improvement of nasal obstruction symptoms and acoustic rhinometry components. Key Words: Septoplasty, batten graft, caudal deviation, septal deviation. Level of Evidence: 3b Laryngoscope, 124:1771 1776, 2014 INTRODUCTION Nasal septal deviation is a common disorder in otolaryngology and one of the major causes of nasal obstruction. Severe nasal obstruction may interfere with daily life; if medical interventions cannot resolve the problem, then it is surgically corrected. 1 Closed septal redisplacement methods were first described and advocated by Adams and Asch in the late 1800s. 2,3 Krieg suggested mucosal preservation and removal of only the deflected cartilaginous segment, which probably gave rise to the more prevalent submucous resection proce- From the Department of Otorhinolaryngology Head & Neck Surgery, Konkuk University, School of Medicine, Seoul, Republic of Korea. Editor s Note: This Manuscript was accepted for publication October 28, 2013. Y.S.C. and J.-H.S. contributed equally to this work. This research was supported by the Basic Science Research Program through the National Research Foundation of Korea, funded by the Ministry of Education, Science, and Technology (2013R1A1A2009589). The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Jin Kook Kim, MD, PhD, Department of Otorhinolaryngology Head & Neck Surgery, Konkuk University, School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul, 143 729, Republic of Korea. E-mail: entalk@kuh.ac.kr DOI: 10.1002/lary.24491 dure that is still practiced by some today. 4 Freer gave credit to an American researcher for description of mucosal flap elevation and removal of the triangular portion of the quadrilateral cartilage. 5 However, these methods are not suitable for correcting caudal septal deviation that interrupts normal nasal breathing as a result of narrowing of the external valve area and nasal valve angle. 6 Surgical management of caudal septal deviation, such as morselization, crosshatching incision, partial thickness incision, swing-door flap, and anchoring suture, has been introduced. 7 Nevertheless, surgeons frequently observe undercorrection or overcorrection of caudal cartilage deviation and weakening of the caudal septal support with subsequent nasal deformity. 8 Therefore, to prevent the occurrence of such subsequent nasal deformities, a batten graft has been introduced for correction of caudal deviation. 9,10 Although a number of studies have used batten grafts for caudal septal support, 11 13 surgical outcomes and technical details of bony batten graft placement for correction of caudal septal deviation have not been well documented. However, the bony batten grafts are usually thinner than cartilaginous batten, and bony batten grafts have more outstanding points that minimize thickening of the anterior caudal margin compared with 1771

Fig. 1. After (A) bilateral flap elevation, (B) the excessive septal cartilage and bone was resected. (C) A caudal septal batten graft was fitted to the desired location. (D) The bony batten graft and the caudal septum were closed using the through-and-through transcartilage sutures. (E) The figure eight suture was done through the bony batten graft and ANS twice. cartilage batten grafts. In this study, we aimed to present our surgical techniques of endonasal septoplasty using bony batten grafts. We also investigated subjective and objective outcomes after endonasal septoplasty using bony batten grafts. the institutional review board of the KUMC. Information about epidemiological data including age and gender was taken from patients medical records. We divided patients into those with turbinoplasty (WT) and those without turbinoplasty (WOT), to compare acoustic rhinometry components. MATERIALS AND METHODS Patients We enrolled 43 patients who presented with symptoms of nasal obstruction and had undergone endonasal septoplasty with bony batten grafts at the Konkuk University Medical Center (KUMC) between February 1, 2012 and October 31, 2012. All of them had significant nasal septal deviations in the caudal septal area. Patients who underwent concomitant rhinoplasty or endoscopic sinus surgery to change the nasal anatomy were excluded from the present study. This study was approved by 1772 Clinical Outcome Assessment Information about epidemiological data including age and gender was taken from patients medical records. Improvements after surgery were assessed subjectively and objectively. Patients were asked to quantify their subjective symptoms, including nasal obstruction and postnasal drip (PND) preoperatively, and the scores were reassessed 3 months after surgery. Each symptom was assigned a score of 1 to 10, according to the severity of the symptoms. To objectively evaluate the correction of deviated nasal septum, acoustic rhinometry (AR) was performed before treatment and 3 months after surgery. AR readings were

Fig. 2. (A) The bony batten graft was harvested from the perpendicular plate and punctured. (B) A through-and-through suture was done to close the batten graft and septal cartilage, and (C, D) a figure eight suture was done at the anterior nasal spine and the graft. obtained using a two-microphone, acoustic rhinometer (SRE- 2000; RhinoMetrics, Lynge, Denmark). An experienced technician performed each AR study in a quiet room with the door closed. Multiple recordings were performed on each side, and the technician performing and interpreting the measurement was blinded to patient variables. To reduce the risk of variability, the free end of the nosepiece was fitted tightly to the nostril while avoiding deformation of the nasal vestibule. The angle of the probe nose piece was 65, and alignment was in a sagittal plane. Patients were asked to hold a short breath and not swallow during measurement. 14 Measurements from the AR graphs were taken from the RhinoScan computerized data program (version 2.6, RhinoMetrics) and were entered into a spreadsheet before calculation. Two measurements were taken from the narrower and wider side of both nasal cavities, respectively. The first deflection of rhinometry, at 1 cm, corresponded to the anterior portion of the isthmus nasi (minimal cross-sectional area [MCA1]); and the second deflection, at 2 cm, roughly corresponded to the anterior portion of the inferior turbinate (MCA2). The area of the narrow part of the nasal cavity after vasoconstriction was compared preoperatively and postoperatively. Surgical Technique After making a hemitransfixion incision approximately 2 to 3 mm behind the caudal region of the concave nasal cavity, the submucoperichondrial flap of the septum was elevated using a Freer elevator via an endonasal approach. Using the Freer elevator, subperichondrial dissection proceeded in the cephalic and dorsal directions. The contralateral flap from the caudal aspect of the cartilage was always elevated without making an incision on the opposite side (Fig. 1A). After bilateral flap elevation, a subperichondrial dissection into the nasal floor was performed to the extent that a graft could be inserted. The curved portion of the excessive septal cartilage and bone was harvested by excision (Fig. 1B), leaving an L-strut of the dorsal and caudal cartilaginous septum at least 1.5 cm long. A caudal septal batten graft created from the harvested perpendicular plate was fitted to the desired location using a straight shape or mild counter-curvature, usually on the concave side (but on both sides if there were concerns about graft tilt; Fig. 1C). The septal cartilage was then separated from the anterior nasal spine (ANS) and maxillary crest for reposition. If there was an excessive cartilage portion, it was removed. Two holes were made by a drill through the ANS and maxillary crest. We punctured the bony graft, made approximately six to eight holes (Fig. 2A), and then the graft was sutured with septal cartilage using three or four stitches (5-0 polydioxanone sutures; Ethicon, Somerville, NJ; Fig. 2B). The gap between the posterior portion of the caudal bony batten graft and the caudal septum was closed using one or two through-and-through transcartilage sutures (5-0 Prolene sutures, Ethicon). Next, for reposition and fixation between ANS and septal cartilage, a figure eight suture was done through the bony batten graft and ANS twice using 5-0 Prolene (Fig. 1E, Fig. 2C, D). The hemitransfixion incision was closed using 5-0 Vicryl (Ethicon), and two or three through-and- 1773

Characteristic TABLE I. Demography of Patients. Value Number of patients 39 Age, yr, mean 6 SD (range) 34.90 6 15.90 (1870) Gender, M:F 33:6 With turbinoplasty:without 23:16 turbinoplasty Mean follow-up period, mo, 6.90 6 2.17 (311) mean 6 SD (range) F 5 female; M 5 male; SD 5 standard deviation. through transmucosal sutures (4-0 Vicryl sutures) were used to fix both mucosae tightly to the newly created caudal septum. The operation was completed once straightening of the deviated caudal septum was confirmed. Some patients with compensatory inferior turbinate hypertrophy, including grades II (moderate enlargement with obvious obstruction) and III (complete occlusion of the nasal cavity), underwent some form of volume reduction of the inferior turbinate, such as radiofrequency volume reduction, outfracture, or submucosal resection. Statistical Analysis Wilcoxon signed rank test was used to compare preoperative and postoperative visual analog scale (VAS) scores, and to compare preoperative and postoperative AR components. Mann Whitney U tests were used to compare VAS scores and AR components between the WT group and the WOT group. A value of P <.05 was considered significant. Data analyses were performed using SPSS for Windows, version 17.0 (SPSS, Chicago, IL). RESULTS Demography of Patients A total of 43 patients were enrolled. Three did not undergo preoperative AR or postoperative AR, and one was lost in the follow-up period. Therefore, these four patients were excluded from this study. The characteristics of the remaining 39 patients are demonstrated in Table I. Improvement of VAS in Symptoms Symptoms including nasal obstruction, mouth breathing, dry mouth, hyposmia, rhinorrhea, epistaxis, snoring, sleep apnea, PND, and headache were all significantly improved after surgery (Table II). Comparison of AR Components in the Convex Side The AR components had significantly improved from preoperative assessments to postoperative assessments (MCA1, from 0.39 6 0.20 cm 2 to 0.61 6 0.18 cm 2 ; MCA2, from 0.40 6 0.43 cm 2 to 0.77 6 0.53 cm 2 ; P <.001). The pre- to postoperative MCA1 was improved for both WT and WOT groups with statistical significance (P 5.001 and P 5.008, respectively). The mean MCA2 had significantly improved after surgery in the WT group, but no significant improvement was found for the WOT group. In both groups, MCA2 had improved significantly after surgery (P 5.045). Comparison of AR Components on the Concave Side The AR components did not significantly improve from preoperative assessments to postoperative assessments (MCA1, from 0.64 6 0.23 cm 2 to 0.60 6 0.18 cm 2 ; MCA2, from 0.80 6 0.67 cm 2 to 0.74 6 0.48 cm 2 ; P 5.990 and P 5.424, respectively). The pre- to postoperative MCA1 did not improve significantly for either the WT or WOT group (P 5.407 and P 5.374, respectively). The mean for MCA2 was improved after surgery in the WT group, but mainly decreased in the WOT group. In both groups, MCA1 and MCA2 did not improve significantly after surgery (P 5.246 and P 5.500, respectively). DISCUSSION Batten grafts are used in various anatomical areas to correct deformities in septorhinoplasty. 11,15 However, the exact indications for using batten grafts in septal deviation are difficult to define. Minor curvatures and angulations of the cartilage can be managed with other conventional techniques, including cutting and suture techniques. 16 Other additional techniques such as suture, swinging door, ethmoid bone sandwich grafting, tongue-in-groove, and extracorporeal septoplasty have been used to manage caudal septal deviation. 17 21 In this study, we evaluated outcomes after endonasal septoplasty using a bony batten graft for caudal septal deviation correction. There were no cases of recurrence. We found that all nasal symptoms were improved after surgery. Other studies have also demonstrated improvement of symptoms in VAS after batten graft surgery. 9,10 Compared to previous studies, this study has three different points. First, bilateral mucoperiosteal flap elevation is necessary for the effective application of the batten graft, because a complete exposure of the ANS and adequate release over the premaxilla are necessary. The exposure must be complete for two reasons: 1) to TABLE II. Comparison of Preoperative and Postoperative Symptoms on VAS. Symptom Preoperative Postoperative P* Nasal obstruction 6.77 6 2.97 2.93 6 2.02 <.001 Mouth breathing 5.53 6 3.34 1.93 6 1.39 <.001 Dry mouth 4.01 6 2.60 1.90 6 1.45 <.001 Hyposmia 3.87 6 3.07 2.70 6 2.23.019 Rhinorrhea 4.53 6 3.26 1.67 6 0.85 <.001 Epistaxis 2.57 6 2.62 1.10 6 0.31.003 Snoring 4.17 6 3.50 2.00 6 1.64.001 Sleep apnea 2.67 6 2.93 1.63 6 1.50.038 PND 3.30 6 2.53 1.73 6 1.41.003 Headache 3.40 6 2.77 2.13 6 2.27.023 *Wilcoxon signed ranks test. Statistically significant. PND 5 postnasal drip; VAS 5 visual analog scale. 1774

facilitate subsequent surgical maneuvers; and 2) to eliminate the restraining influence of the contracted soft tissue envelope, which can keep the caudal septum in its deviated location. 22 Second, separation of ANS and septal cartilage is necessary, because caudal deviation in a cephalocaudal direction or anteroposterior direction produces an excessive cartilage portion or cartilaginous subluxation to ANS. Third, once the caudal septum is separated from the anterior nasal spine for correction, the septum batten graft complex needs to be securely reattached to prevent recovery of deviation. We settled this problem by making two-point holes in the ANS and maxillary crest. Using only one-point figure eight sutures is not sufficient to sustain the recoiling force of cephalic caudal deviation, but two-point sutures provided sufficient support to prevent the recovery of deviation. In addition, the use of additional inferior turbinate volume reduction or turbinoplasty was found to influence the outcome. In MCA1, both groups showed improvement on the convex side. However, we found different levels of improvement between groups in MCA2. The MCA1 for the postoperative concave side was not statistically different between the groups. However, there was a decreasing trend, because various patterns of compensatory hypertrophy of inferior turbinate on the concave side may have distorted the result of AR. This finding had also been demonstrated in another report, which showed an increase of MCA on the concave side in septoplasty and concomitant turbinoplasty, but without statistical significance. 10 Another study showed VAS improvement with batten grafting compared to other surgical techniques. 9 The authors did not apply the AR, because the nosepiece could distort the caudal septum. 23 The related drawback of cartilaginous batten graft is an increase in caudal thickness. Conversely, the bony batten graft is beneficial for minimizing the caudal thickening. However, we selected the MCA1 and MCA2 as objective parameters but did not select area parameters such as VOL1 (volume of the segment located from the nostril to the anterior portion of the isthmus nasi) and VOL2 (volume of the segment located from the nostril to the anterior portion of the inferior turbinate) due to inaccuracy after the narrow point. 24 There are several other advantages in using caudal bony septal batten grafting. First, because the septal cartilage is preserved, revision surgery can be easily performed using the stored cartilage if problems recur. Second, the intrinsic caudal septal support is maintained. A previous study emphasized that the structural integrity of the caudal septum must not be compromised by incisions or excisions. 22 Accordingly, straightening and strengthening of the caudal septum is achieved with batten grafting. In addition, if necessary, the caudal septum can be lengthened by modification of the batten graft. Third, intraoperative verification of batten grafting is possible, and surgical outcome is more predictable. Although the perpendicular plate was used as the bony batten in the present method, the vomer can be used by trimming thinly with a drill in the case of insufficient perpendicular plate. There are possible disadvantages to bony batten grafting. First, there is a possibility of bone resorption and subsequent recurrence of the deviation. 10 However, in this study, there was no recurrence. According to previous studies, the bone of the perpendicular plate is so membranous that it shows little resorption. 19,25 Also, the cartilaginous batten graft has a possibility of scoring. Second, contralateral nasal airway may be narrowed by the batten graft. In our study, however, there was no case of postoperative nasal obstruction, because bilateral nasal valve symmetry is created through orientation of the concave side of the batten graft. We also demonstrated a slightly decrease in the concave side, without significance. Third, there is a possibility for decreased long-term stability of the caudal septum because of a separation in the junction between ANS and caudal septum. Because of this, we have reinforced the caudal septum with batten graft and ANS with rigid fixation. Long-term follow-up studies are needed to further clarify this issue. Postoperative infection was developed in one case and was well controlled with oral antibiotics. Infection was the result of incision site infection. There are some limitations in the present study. It was difficult to find a control group to compare different surgical techniques. Further studies are needed to compare different methods with patients in the same condition. Other additional limitations were the relatively short follow-up period, all patients being of Asian descent, and the small size of the patient population. CONCLUSION We conclude that endonasal septoplasty with bony batten grafting is a safe, effective technique for correction of caudal septal deviation, improving both subjective and objective outcomes with an acceptable complication rate in most cases. BIBLIOGRAPHY 1. Pastorek NJ, Becker DG. Treating the caudal septal deflection. Arch Facial Plast Surg 2000;2:217 220. 2. Adams W. On the treatment of broken-nose by forcible straightening and mechanical retentive apparatus. Br Med J 1875;2:421 422. 3. Asch A. Treatment of nasal stenosis due to deflective septum with and without thickening of the convex side. Laryngoscope 1899;6:340. 4. Krieg R. Resection der Cartilago Quadrangularis Septi Nasem sur Heilung der Scoliosis Septi. Medicinishes Cocrespondenz blatt Wurtenburgishen Artzlicken Verein Stuttgart 1886;56:201. 5. Freer OT. The correction of deflections of the nasal septum with a minimum of traumatism. JAMA 1902;38:636. 6. Garcia GJ, Rhee JS, Senior BA, Kimbell JS. Septal deviation and nasal resistance: an investigation using virtual surgery and computational fluid dynamics. Am J Rhinol Allergy 2010;24:e46 e53. 7. Fry HJ. Interlocked stresses in human nasal septal cartilage. Br J Plast Surg 1966;19:276 278. 8. Lee BJ, Chung YS, Jang YJ. Overcorrected septum as a complication of septoplasty. Am J Rhinol 2004;18:393 396. 9. Kim JH, Kim DY, Jang YJ. Outcomes after endonasal septoplasty using caudal septal batten grafting. Am J Rhinol Allergy 2011;25:e166 e170. 10. Wee JH, Lee JE, Cho SW, Jin HR. Septal batten graft to correct cartilaginous deformities in endonasal septoplasty. Arch Otolaryngol Head Neck Surg 2012;138:457 461. 11. Dingman RO. Correction of nasal deformities due to defects of the septum. Plast Reconstr Surg (1946) 1956;18:291 304. 12. Dupont C, Cloutier GE, Prevost Y. Autogenous vomer bone graft for permanent correction of the cartilaginous septal deviations. Plast Reconstr Surg 1966;38:243 247. 13. Haack J, Papel ID. Caudal septal deviation. Otolaryngol Clin North Am 2009;42:427 436. 14. Harar RP, Kalan A, Kenyon GS. Improving the reproducibility of acoustic rhinometry in the assessment of nasal function. ORL J Otorhinolaryngol Relat Spec 2002;64:22 25. 1775

15. Jang YJ, Kim JM, Yeo NK, Yoo JH. Use of nasal septal bone to straighten deviated septal cartilage in correction of deviated nose. Ann Otol Rhinol Laryngol 2009;118:488 494. 16. Jang YJ, Yeo NK, 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 1260. 17. Ellis MS. Suture technique for caudal septal deviations. Laryngoscope 1980;90:1510 1512. 18. Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg 1999;1:246 256; discussion 257 258. 19. Metzinger SE, Boyce RG, Rigby PL, Joseph JJ, Anderson JR. Ethmoid bone sandwich grafting for caudal septal defects. Arch Otolaryngol Head Neck Surg 1994;120:1121 1125. 20. Andre RF, Vuyk HD. Reconstruction of dorsal and/or caudal nasal septum deformities with septal battens or by septal replacement: an overview and comparison of techniques. Laryngoscope 2006;116:1668 1673. 21. Gubisch W. The extracorporeal septum plasty: a technique to correct difficult nasal deformities. Plast Reconstr Surg 1995;95:672 682. 22. Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques. New York, NY: Springer; 2002. 23. Miman MC, Deliktas H, Ozturan O, Toplu Y, Akarcay M. Internal nasal valve: revisited with objective facts. Otolaryngol Head Neck Surg 2006; 134:41 47. 24. Fisher EW. Acoustic rhinometry. Clin Otolaryngol Allied Sci 1997;22:307 317. 25. Peer LA. Fate of autogenous human bone grafts. Br J Plast Surg 1951;3: 233 243. 1776