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                  By LINDSAY GRAY (Perth, Y. Australia)

The Deviated Nasal Septum—II—Prevention and Treatment

      nH n   i i i i i i i i i i i i i i I-... H i i i . i i i i...
Lindsay Gray
    2. Category 2 cases all showed considerable deviations to the same side
as originally found, i.e. the tes...
The Deviated Nasal Septum—II—Prevention and Treatment
buckled cartilage tip deformity. However, its main shortcoming is th...
Lindsay Gray

                                        FIG. 2.
Diagrammatic representation of Sub Mucous Repositioning o...
The Deviated Nasal Septum—II—Prevention and Treatment

                                       FIG. 4.
    To demonstrat...
Lindsay Gray
midline. The cartilage is incised through to the perichondrium longitudi-
nally to break the spring of the be...
The Deviated Nasal Septum—II—Prevention and Treatment
or a plaster of Paris splint keeps the grafts to the bridge moulded ...
Lindsay Gray
ointment applied to prevent drying and crusting. The nose is sucked out
and toileted by the surgeon every 2-4...
The Deviated Nasal Septum—II—Prevention and Treatment
The septum is squeezed and manipulated and then splints tied in as f...
Lindsay Gray
CARTER, W. W. (1930) Ann. Otol. (St. Louis), 39, 199.
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Deviated Nasal Septum


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Deviated Nasal Septum

  1. 1. THE DEVIATED NASAL SEPTUM—II— PREVENTION AND TREATMENT By LINDSAY GRAY (Perth, Y. Australia) THIS paper is to demonstrate that_the deviated nasal septum can be treated at an early agej and to advocate that treatment should be as conservative as possible. PREVENTION By this is implied simple repositioning of the septum by manipulation as soon as possible after the initiating trauma, before fixation of the septum has occurred in its new position ,_Direct trauma at anv age of life can cause the cartilaginous type of deformity of the anterior third of the septum, with dislocation from the groove on the nasal spine or buckling of the cartilage. This simple type is readily amenable to repositioning by lifting the septal tip with Walsham's septal forceps, and manipulating the cartilage back to the midline. Any fracture of the bony arch of the nose must be reduced initially. If there is present a septal deformity due to deviation of the vomer bone—i.e. the combined type (Gray, 1965), then manipulation rarely will give a midline septum. Over the last 2 years attempts have been made to straighten deviated septums by simple manipulation by using a modified Walsham septal forceps (Fig. 1). The blades are 6 mm. wide and 17 mm. long with a simple block which only allows closure to 1-5 mm. The technique has been used on just under 100 cases. These were in two groups—(a) birth to 1 week old (69 cases), and (b) 6 to 24 months old (28 cases). These were selected by the passing of testing polythene struts as previously described. Method: No anaesthesia was used for the babies and it does not appear to be warranted, for the procedure takes only 30-40 seconds and the babies usually settle again within a minute. A general anaesthetic was used for the older group, as the manipulation was part of a minor operation such as myringotomy or antral lavage. Thelubricated blades (K.Y. Jelly was the usual lubricant) are inserted or wriggled into the nose and gently closed until resistance is felt. (The babe is held by a nurse to prevent undue movement.) Firm pressure is then exerted caudally on to the middle of the floor of the nose, depressing the arch of the palate to reduce the initiating _deformity. No attempt is made to depress the posterior end of the floor, for 806
  2. 2. The Deviated Nasal Septum—II—Prevention and Treatment nH n i i i i i i i i i i i i i i I-... H i i i . i i i i i i i . i t i t i FIG. I. Modified Walsham Septal Forceps for Infants. the palatine bones are not involved in the initiating deformity (as postu- lated in 3). To apply the blades along the floor of the nose, the handles must be elevated cranially causing a temporary deformity of the soft tissues of the nasal tip. The head is held in the left hand (if one is right handed). The left thumb is applied firmly to the joint of the forceps, thus exerting pressure caudally on the blades, and tends to act as a fulcrum preventing undue deformity of the nasal tip. The firm caudal pressure is continued for 15-20 seconds and the septum is manipulated back to the midline, and then the pressure on the floor is eased and the forceps removed. The passageway is then retested and the strut should now pass readily to the back of the nose. Results: This is a preliminary report, as insufficient time has elapsed and insufficient numbers have been reviewed, but the following observa- tions have been able to be made. Three categories have been reviewed about a year after the original assessment: (1) those with septums classified as straight at birth, (2) those classified as bent, and (3) those classified as bent but which had been manipulated. Categories 1 and 2 have acted as controls for 3. 1. Category 1 cases were still predominantly straight although a few had definite displacements. This is in keeping with the original assessment which only recorded the gross deviations causing frank obstruction and not the minor irregularities (Gray, 1965). 807
  3. 3. Lindsay Gray 2. Category 2 cases all showed considerable deviations to the same side as originally found, i.e. the testing strut would not pass. 3. Category 3 cases predominantly showed only a little irregularity and the testing strut passed through to the back of the nose. In some the deformity was still present. In one there was now a deviation to the opposite side suggestive that during manipulation the deformity had been over-corrected. 4. Jji the 6-24 month old group over half were improved at operation, but practically all had recurred to a greater or lesser extent by the time of reviewal. This is explained by referring to Case B of figures 3 and 4 of my previous paper (Gray, 1965) which shows a septum of a 6 month old child with a permanent bony deformity which could be corrected only by surgery. 5. Manipulation just after birth in selected cases will prevent develop- ment of a severe combined type of scptal deviation in a high proportion of cases but is ofjnuch less success if done after 6 months of age. TREATMENT It is stressed that with every combined deviation there are always associated deformities of the lateral walls (turbinates, ethmoid bullae) mainly on the concave side of any septal deviation. This is most likely due to the reaction of the body attempting to remake the normal anatomy and physiology of the nose, i.e. as stated by Proetz (1953) "moist slit-like passages everywhere". This develops pari passu with the growth of the septal deformity, is readily demonstrated by coronal section of the nose and may be well developed by the age of 6 months (Gray, 1965). Thus the nose must be considered as a WHOLE and attention given to the lateral walls as well as the septum if normal physiology is to be regained. The basic reason for operation on the deviated septum is to improve the nasal physiology, and the indication is deviated septum with complica- tions. The complications which may affect the nose, the septum, the sinuses, the ears or the throat are mainly impaired nasal respiration, epistaxis, recurrent sinusitis, nasal polyposis, recurrent throat infections and recurrent or chronic ear disease—particularly unilateral ear disease. These will be discussed in a further paper. Many operations have been devised for straightening a deviated septum, and although authors (Carter, 1930; Goldman, 1952; Wexler, 1955) have advocated retention of as much cartilage as possible, the main operation described in the text books is the "Sub Mucous Resection" or S.M.R. This entails leaving a skeleton support and filleting out the cartilage and bony spur. This is a destructive operation and has the well-known potential complications of loss of support of the bridge, flapping and noisy septum and septal perforation; and also is not very suitable for the disorganized 808
  4. 4. The Deviated Nasal Septum—II—Prevention and Treatment buckled cartilage tip deformity. However, its main shortcoming is that because it is so destructive it should not be done until the nose has stopped growing. At times, in spite of an obvious need for straightening a septum in a child, no attempt has been made to correct the deformity, thereby often allowing irreversible pathological changes to occur in the nose or ears. The following procedure is an attempt to overcome these disabilities, and has been used in over 300 cases in the last 4 years with very satis- factory results. It has been used for all ages from 4 years old. Technically it has been found too difficult to do satisfactorily under 4 years of age. Basically it is a repositioning of the septum done submucosally (see Figs. 2 and 3). After mobilization of the septal components by incision, chiselling, fracture and removal of projecting bumps, the pieces of the septum are held in place by polythene splints (Figs. 4 and 5). A modification of this technique has been used on children for the last 12 years without any ill effect on the growth of the nose. It has been possible to observe a nose now growing straight, the disappearance of a columella deformity or the improvement in nasal physiology. The technique has been evolved by a certain amount of trial and error and from perusal of the literature. Its big attribute is that it produces an almost normal anatomical structure in its normal position, and gives the nose a chance to regain its normal physiological function. Anesthesia: In adults a local anaesthetic is much preferred. The premedication is most important. Light nourishment such as tea and toast is given 2 hours before, together with a sedative (as pentobarb. sodium gr. 3), and 1 hour before—morphia gr. 1/6 if under 10 stone or gr. if over. The nasal vibrissae are clipped in the ward. The nose is anaesthetized as for routine S.M.R. The columella is injected with local anaesthetic with adrenalin. If any turbinate is to be reduced it is injected later. By the time the injection is completed the nose is anaesthetized and ready for the operation to proceed. With local anaesthetic there is usually very little bleeding, but with a general anaesthetic the amount may vary from very little to an annoying amount. A general anaesthetic is used for children and selected adults, and then the nose is packed with adrenalin gauze and injected as above. Operation Technique: A headlight with magnification (as Storz loupe) is always used and has been found to give excellent illumination, while the magnification assists greatly the ease and accuracy of handling the tissues. A vertical incision, a few millimetres behind the front end of the cartilage, is made on the side opposite to the deviation. The perichondrium is elevated, exposing all the tip on both sides. The periosteum is elevated over the maxillary crest on both sides. The direction of operation is now around the tip on to the side of the deviation. The perichondrium is elevated from all the cartilage on that side, for due to the deformity the cartilage extends right to the back over the ethmoid plate on the side of the
  5. 5. Lindsay Gray FIG. 2. Diagrammatic representation of Sub Mucous Repositioning of the Septum. Note method of reduction of inferior turbinate with covering over of the raw surface. FIG. 3. Diagrammatic demonstration showing: (1) Criss-crossed area—area of removal of cartilage, and trimming or removal of bone. (2) Continuous lines—showing the slatting cuts in the cartilage, some communicating with the vertical septal cut. (3) Interrupted lines—show lines of bony fracture done either by pressure on the thin bone or assisted by chiselling. (4) The method of suture around the nasal spine. spur (Gray, 1965). This leaves the cartilage attached to the perichondrium on the side of the incision. A strip of cartilage (usually about 3-5 mm. wide) is excised from the lower border along the edge of the vomer spur. This allows easier access to elevate the periosteum off the vomer (which is then done), and later allows the cartilage to be brought to the midline without interfering with the vomer. The cartilage is then incised vertically at the anterior edge of the perpendicular plate of the ethmoid, and the cartilage plate thus mobilized is pushed medially, allowing better access. The 810
  6. 6. The Deviated Nasal Septum—II—Prevention and Treatment FIG. 4. To demonstrate the usual position of the splint and strut in each nasal cavity. FIG. 5. Plastic Splints and Perspex Struts—see addendum for particulars. periosteum is then separated from the vomer on the other side. The spur is shaved off the vomer or if it is too thick the whole thickness of the bone is removed. Any projecting pieces are thinned down or removed. The vomer is chiselled along the floor of the nose, and the ethmoid chiselled along the roof so as to enable the bony posterior portion to be infractured to the 811
  7. 7. Lindsay Gray midline. The cartilage is incised through to the perichondrium longitudi- nally to break the spring of the bend. Two cuts are made near the roof to ensure that the top will fall easily into the midline. These cuts extend from the cut posterior edge of the cartilage to within about 2 cm. from the anterior edge, and parallel incisions are made about i cm. apart on the remainder of cartilage (see Fig. 3). Incisions are made in between these cuts, extending from about 1 cm. in front of the posterior incision to about 1 cm. from the front edge. The pieces of cartilage are held in place by the intact perichondrium and should sit easily in the midline. If the cartilage does not, it must be trimmed or slatted further. If there has been dis- organization of the tip, the pieces of cartilage must be mobilized, at times nearly completely, but left attached to the roof of the nose. The edge of a severe buckle must be excised but as little as possible of the cartilage removed. The pieces may be held in place by transfixing with straight skin needles and fixed by using mattress catgut sutures through the mucosa. If necessary, a new bed for the anterior end is made with scissors into the columella. The dental instrument, Ash Sealer No. 152, has been found to be a most useful adjunct to the normal instruments. Drainage incisions are then made through the mucosa on the side of the deviation at the posterior end and anteriorly near the roof. These are most important as they allow drainage when the splints are in place. The lateral wall of the nose is then dealt with to bring it into normal alignment with the new position of the septum. This often has to be done at an earlier stage to allow the septal operation to proceed. As the enlarge- ment of a middle turbinate is often due to enlarged air cells, simple compression and pushing laterally may be sufficient. The inferior turbinate is incised (Fig. 2) along the edge along the line of the long axis and the bone exposed. The edge of the bone is then reduced by nibbling and the redund- ant lateral quadrant of mucosa is then removed (such as with a Struychen's Nasal Punch). This allows the front flap to fold over neatly. The posterior end is reduced if necessary. If there has been a big mucosal tear such as over the spur, the edges are approximated with catgut suture. This enables primary healing and protection of the underlying cartilage or bone. If there is a frank loss of mucosa it can be covered with a flattened out piece of mucosa from the trimming of the inferior turbinate. This is placed over the area before the splints are finally inserted and covered with a piece of oil silk which holds it in place and allows the splints to be inserted without disturbing the graft. If there is a dip in the nasal bridge due to loss of cartilage support, this often can be rectified by burrowing a hole under the skin from the top of the mucosal incision. It is made above the cartilage and the dip is filled with fibrous scar tissue and pieces of removed bone and cartilage. The splints give support until the septum is firm. Firm pressure by Elastoplast 812
  8. 8. The Deviated Nasal Septum—II—Prevention and Treatment or a plaster of Paris splint keeps the grafts to the bridge moulded into position. The mobile anterior end of the septum is then immobilized to the mid- line by suturing around the nasal spine (Fig. 3). 4/0 Mersilk has been found most suitable as it is strong and fine. It is inserted through the cartilage and then back again and through again in a type of figure 8 to prevent slipping. It is inserted on a fine No. 5 or 6 eye needle which is held with a Gillies (Stille) needle holder so that the needle is in the line of the forceps and the eye of the needle fits into the slotted blade. It is best held like this to prevent the needle breaking and to enable the needle to be pushed accurately and laterally through the septum. The septum is held with fine long plain forceps (as Maclndoe's Forceps 6 in.). The septum is given its final gentle squeeze and manipulation with Walsham's septal forceps, and the mucosal incision sutured. The appropriate sized polythene splints (see Fig. 5 and addendum) are greased and inserted. These should readily slide in and sit easily on each side. The anterior mattress suture is inserted through the anterior holes, with the splints in situ, using 2/0 Mersilk on a straight skin needle. The splints are held in place with the long forceps, which enables the splints to be accurately positioned in the nose. The splints are removed and the posterior suture is threaded through the splints when they are lying outside the nose. 2/0 Mersilk on a No. 5 or 6 eye needle is used, the septum being held with the long forceps and the needle held in the Gillies forceps as above. The suture is inserted under direct vision. To insert the needle through the septum, the needle and blades of the forceps are pushed medially while the handle is revolved laterally. The needle is then retrieved from the opposite side, threaded through the splint and then reinserted about 6 mm. above the first insertion. The site, which one judges by experience, is about 2 cm. from the anterior suture and is about the maximum distance back that this can comfortably be done. The fact that the site of insertion through the septum of the posterior mattress suture does not correspond accurately to the posterior holes on the splints is not important, for the anterior suture holds the splints accurately in place and the posterior one is just a holding suture. The splints are reinserted and as they are comparatively soft the longitudinal rigidity is increased by inserting perspex struts (Fig. 5 and addendum) underneath the sutures (Fig. 4). The splints and struts are held with the long forceps and the sutures are tied fairly firmly but not tightly (Fig. 4), using the Gillies forceps. The nostrils are packed with well- greased gauze (as Calgetex gauze with Ung. Neomycin). Postoperatively an antibiotic cover is usually given for 4-5 days, the packs removed in 24 hours, and the patient discharged on the second day. The nares are toileted by the patient 3 times a day and a small amount of 813
  9. 9. Lindsay Gray ointment applied to prevent drying and crusting. The nose is sucked out and toileted by the surgeon every 2-4 days. The splints, which cause very little if any discomfort apart from blockage, are usually removed in 9 or 10 days. If there has been disorganization and buckling of the tip they are left in for 14 days to enable the tissues to thicken up and give support. Complications are very few. Secondary haemorrhage about the 5th-6th day has occurred in several cases from the posterior end of the cut inferior turbinate. Although it is easy to arrange for the flap to cover over the cut edge in the anterior part, it is difficult to do so accurately at the posterior end and thus a raw surface may be left. Treatment entailed removing the strut on that side and the haemorrhage was readily controlled by the use of an inflatable nasal bag (as Down Bros L 62-1). In one case the posterior end of the spur near the sphenoid had not been sufficiently reduced, and the posterior end of the splint caused irritation and bleeding. This required removal of the splint and strut. This would be suspected if haemorrhage occurred on the opposite side to the reduced inferior turbinate. Perforation is unlikely to occur because of the strength of the full thickness of a normal septum. A perforation has occurred in the superior portion above the splints but not since an adequate drainage incision has been made, as mentioned above. A tendency for the buckle to recur is prevented by ensuring that the septum sits in the midline after slatting and mobilizing the septum, and by the suture around the nasal spine. The splints cause very little reaction and inconvenience and in two cases when left in situ for 3-4 weeks, no infection or nasal reaction occurred. The operation is time consuming—taking i | to 2 hours. Although this technique is applicable to all cases at all ages, particular mention is made of its use in the following types: 1. All children. 2. The septal deformity associated with cleft lip and palate. Attention to the combined type of deviation of the septum improves the airway, and repositioning of the deformed anterior part of the cartilage may elevate the tip, improving the appearance and also modifying the requirements of further plastic surgery. Therefore this should be done in association with the plastic surgeon and before secondary surgery on the nasal openings is performed. 3. The post-traumatic deformed anterior 1/3 of the cartilage—the so-called concertina deformity—and the associated depression of the bridge. 4. Septal haematoma with or without abscess formation: The mucosa is incised horizontally low down and the clot and infection sucked out and a drainage incision is made at the top of the septum. If a marked septal spur is present, a routine septal approach and removal of the spur can be done. 814
  10. 10. The Deviated Nasal Septum—II—Prevention and Treatment The septum is squeezed and manipulated and then splints tied in as for routine septal operation. The splints are left 14 days and support the thinned cartilage and allow the septum to become firm. Summary 1. Although this is a preliminary report, it is put forward thatjnanipu- lation of the septum just after birth, in cases selected_by passing a testing polythene strut, will prevent in a high proportion of them, the develop- ment of a combined type of septal deformity. 2. Manipulation will only have a small measure of success if done between the ages of 6 and 18 months. 3. The nose must be considered as a WHOLE and attention given to the lateral walls as well as the septum if normal physiology is to be regained. 4. A surgical_technique called sub mucous repositioning of the septum is described which is applicable to all ages over 4 years. Basically it is repositioning of the septum after it has been mobilized submucosally. The septum is held in position by polythene splints which are described. 5. This technique is particularly applicable to: (a) all children, (b) cleft lip and palate cases, (c) post traumatic deformity of anterior end of septum, (d) infected septal haematoma. Acknowledgment Grateful acknowledgment is made to Mr. R. Plummer and his associ- ates of the Photographic Department of the Sir Charles Gairdner Hospital for the reproductions. Addendum Polythene splints are made from Regular Polythene sheeting i/i6th inch. Two pairs of holes are about 6 mm. apart. The anterior pair arefabout 8 mm. from the front end and the posterior pair 16 to 18 mm. further back from the anterior holes. DIMENSIONS OF SPLINTS. No. Length Height Usual Age Strut i 51 mm. 14 mm. 4-6 yrs. 44 mm. 2 51 mm. 17 mm. 5-8 yrs. 44 mm. 3 58 mm. 17 mm. 8-12 yrs. 48 mm. 4 58 mm. 20 mm. Over 11 yrs. 48 mm. 5 65 mm. 20 mm. Adult 54 mm. Perspex struts are made from Perspex sheeting 1-5 mm. thick and are 5 mm. wide. Lengths are 54, 48 and 44 mm. long. 815
  11. 11. Lindsay Gray REFERENCES CARTER, W. W. (1930) Ann. Otol. (St. Louis), 39, 199. GOLDMAN, I. B. (1952) / . Int. Coll. Surg., 17, 167. GRAY, L. P. (1965) / . Laryng., 79, 567. PROETZ, A. W. (1953) Essays on the Applied Physiology of the Nose. 2nd edition. St. Louis. WEXLER, M. R. (1955) / . Amer. med. Ass., 157, 333. Lindsay P. Gray, 194 St. George's Terrace, Perth, Western Australia. 816