Septal deviation represent a major cause of aesthetic disorders and respiratory obstruction. The traditional septoplasty techniques may often be inadequate to treat severe deviations. This study was designed to evaluate the effectiveness of the modified technique of extracorporeal septoplasty in terms of subjective improvement in validated NOSE score post-operatively and complications in short term (3months).
A total of 20 patients with severe septal deviation were evaluated in the Otolaryngology Outpatient Department in Al-Immamain Al-Khadimain Medical City, from March 2017 to February 2018. All were undergoing extracorporeal septoplasty (ECS) and assessed pre and post-operatively clinically and endoscopically and subjective evaluation of the respiratory function was obtained by mean of Nasal Obstruction Symptom Evaluation (NOSE) scale which compared with the results obtained preoperatively and at 1 and 3 months post-intervention.
NOSE scores at 1 and 3 months follow-up demonstrated a statistically significant improvement ( P < 0.0001) compared to preoperative values. There were no complications recorded.
The modified extracorporeal septoplasty technique proved to be functionally effective at 3-month follow-up in cases of severe septal deviation.
Modified Extracorporeal Septoplasty is very effective clinically and statistically for severe septal deviation.
Elevated the surgeon the ability to correct the septum under direct visualization.
ECS have less complications.
Septal cartilage is forming a partition between right and left nasal cavities and provides support to the tip and dorsum of the cartilaginous part of the nose [ ]. It is made of a sagittal plate of cartilage and bone covered by respiratory mucosa and the membranous part connects columella to quadrangular cartilage [ , ]. Surgery for correction of deviated nasal septum evolved over the years. Submucosal resection of septal cartilage was initially described by Ingals in 1882 [ ]. In 2006, the Gubisch technique used to simplify the reconstruction and to decrease the aesthetic complication along bony and cartilaginous dorsum was modified [ ]. The complications of Extracorporeal septoplasty include Haematoma, perforation, nasal shape changes as tip ptosis, and dorsal nasal saddling, synechiae, loss of sensation in upper incisors teeth, non-absorbable holding suture showing through the skin, and destabilization of the key-stone area [ ].
The modified extracorporeal septoplasty approach was described based on partial resection of the cartilaginous septum, with preservation of a super caudal L-strut measuring approximately 0.5–1 cm in height. Based on that for 3-month follow-up, we demonstrated this technique to be functionally and aesthetically effective in addressing severe septal deviation by using the validated NOSE score, before and after surgery, and besides that to quantify symptom improvement and confirm the validity and usefulness of this method in treating severe septal deviation. ( Supplement 1 ).
This study is designed to evaluate the effectiveness of the modified technique of extracorporeal septoplasty in terms of subjective improvement in validated NOSE score post-operatively and complications in short term (3 months).
Patients and methods
Study design and setting
A prospective study was conducted in Al-Imamian Al-Khademain Medical City from March 2017 to February 2018 for patients with severe septal deviation who underwent ECS.
Data collections and sources
Stewart et al. addressed and developed the Nasal Obstruction Symptom Evaluation (NOSE) scale within the scope of a multi-center study [ ]. This measure was validated by the assessment and calculation of reliability, validity, and response sensitivity. During this process, the measure was reduced to five-item [ ]. The NOSE scale is a valid, reliable, and responsive instrument that is brief and easy to complete and has potential use for outcomes studies in adults with nasal obstruction [ ]. According to this scale, patients were asked to evaluate the severity of their nasal congestion, their difficulty in nasal breathing, their difficulty in breathing during their sleep, and their difficulty in breathing overall. The severity of their symptoms was recorded based on a scale from zero to four, 0 standing for the absence of the symptom and 4 for the severe problem. Possible scores ranged from zero to 20 and higher scores implied a greater subjective degree of obstruction [ ], supplement.
Patients were grouped according to the preoperative septal deviation as follows: mild (one-third reduction of the nasal cavity), moderate (half reduction), and severe (two-thirds reduction) [ ].
Chronic nasal obstruction due to severe septal deviation.
The patient needs other nasal surgeries like rhinoplasty and FESS.
In all patients, general anesthesia was provided with per-oral endotracheal intubation in the midline with the pharyngeal pack. Then sterilized the whole face, and bilateral anterior nostril with povidone-iodine solution 10%. The patient was placed in reverse Trendelenburg position on the operating table and the head turned toward the surgeon. Then the patient was draped with exposed eyes and nose. The hemi-trans-fixation incision was made on the left or right according to the deviation side. Then the bilateral mucoperichondrial –mucoperiosteal flap was raised, first on the concave side than on the other side. After that, the posterior chondrotomy was done. The inferior tunnel was done on the floor of the nasal cavity. The majority of the cartilaginous septum was resected with blade no.15 leaving 0.5–1.5 cm dorsal remnant according to extent of deviation in the cartilage (if caudal part of the septum is straight then 0.5 cm left caudally). The harvested cartilage was reshaped and reconstructed by either excision the redundant cartilage or fracture line, the straighten pieces were sutured together to provide a stable reconstructed septum. The bent deformities were straightened by reduction tension on the cartilage, or partial-thickness releasing incision on the convex side of the cartilage with a knife to straighten the bent cartilage. We do multiple holes by drilling the cartilage for securing fixation intraoperatively and when tissue growth through them post-operatively. The new cartilaginous septum was re-implanted between the mucoperichondrial flap (the anterior be posterior and visa-versa). The dorsal fixation of neoseptum with the remnant cartilage left behind in the dorsum with 2 stiches (absorbable 3l0) through and through and the same for caudal fixation (if caudal remnant left behind). The small piece of cartilage was smashed and placed close to the nasal spine and the neoseptum land on it with no need for suturing it to the nasal spine. The hemi-trans-fixation incision was closed with 1–2 stiches (3l0 absorbable). Then, the silastic splints were placed on both sides of the septum and fixed to it through and through non-absorbable (silk) caudally. The bilateral anterior nasal packing was done. Lastly, the dressing was applied as shown in ( Figs. 1–8 ).
The potential possible complication include:
Infection at site of incision: This prevented by clean operation sites sterilized with povidone-iodine solution 10%, well dressing and described I.V. antibiotics postoperative (I.V. for one day), and (I.M. for 6 days). In addition nasal douche for 10 days.
Change in the shape of the nose: This handled by Silastic splints were placed on both side of the septum and fixed to it with through and through non-absorbable (silk) caudally. Also avoid over resection of the caudal septum or loss of dorsal nasal support.
Haematoma: This handled by used quilting stitch and by make multiple holes were made by drilling the cartilage for securing fixation intraoperatively.
Recurrence: Follow up weekly in the 1st month then monthly for 3 months. In each visit the patients were evaluated according to NOSE score, anterior rhinoscopy, and nasal endoscopy.
Septal perforation: This handled by careful and perfect hemitransfixation incision was made on left or right according to the deviation side. Bilateral mucoperichondrial –mucoperiosteal flap were raised, first on concave side then on the other side. Posterior chondrotomy was done. Inferior tunnel was done on the floor of nasal cavity.
All patients received IV antibiotics with analgesia. Patients were discharged to home the next day (if they were stable) on IM antibiotics for 6 days then oral antibiotics for 5 days. The anterior nasal pack was removed after 1–2 days. Silastic splints were removed after 5–7 days (post-op.). Nasal douche for (7–10) days after anterior nasal packs were removed. Follow up weekly in the 1st month then monthly for 3 months. In each visit, the patients were evaluated according to NOSE score, anterior rhinoscopy, and nasal endoscopy.
The descriptive statistics were analyzed using SPSS 20 (Chicago, USA) to determined frequencies for variables. Categorical data presented by frequencies and percentages. Chi–square test was used to assess the statistical association between study groups and postoperative evaluation criteria. A level of P value less than 0.05 was considered significant.
In our study 25 patients underwent ECS, 5 of them couldn’t come back for the follow-up, and only 20 patients complete enrolling in this study. In all patients, nasal obstruction was the chief complaint, but it was bilateral in 75% and unilateral in 25% as shown in Table 1 . 20% of the patients were founded to have crustations in the follow-up period, while 5% of them had an infection at the site of incision, as shown in Table 2 . NOSE score evaluation pre- and 1-month post-operation were significant ( P < 0.001), as shown in Table 3 . NOSE score evaluation for preoperative and 3 months postoperative by Yates chi-square test for p-value which was significant <0.001, as shown in Table 4 . There was not significant NOSE score between the results of 1 month and 3-month post-operative, as shown in Table 5 .