Pediatric Septoplasty

doi:10.1016/j.otc.2009.01.013

Otolaryngologic Clinics of North America

Volume 42, Issue 2, April 2009, Pages 287-294

https://doi.org/10.1016/j.otc.2009.01.013 Get rights and content

This article discusses the importance of obtaining the correct anatomic location of a nasal obstruction in the pediatric patient, the relative and absolute indications for septoplasty, and surgical techniques. Because disruption of the developing nasal septum can alter craniofacial growth patterns, the current understanding of the effect of septoplasty on craniofacial growth is also discussed.

Section snippets

Historical overview: animal studies

Pediatric septoplasty became the focus of multiple animal studies over the next 20 years, a few of which are landmark studies worth recognizing because they are often referred to when discussing this subject. Their results varied, and depending on which model was used, either confirmed the fears of clinicians or showed no effect on midface growth.

Sarnat and Wexler showed that moderate-size perforations in the nasal septum of young rabbits led not only to the expected saddling of the nasal

Historical overview: human studies

With the later animal studies showing that a growing nasal septum could be altered without affecting long-term growth, longitudinal studies on children began appearing, with encouraging results.9, 10 Most of the studies were on children with a strong indication to undergo septal manipulation at a young age. McComb began performing primary rhinoplasty when repairing cleft lip nasal deformities in young children in the 1970s and noted no long-term growth effects. He performed an 18-year

Prevalence

In contrast to the adult population, septoplasty is not a commonly performed operation in children, with most series averaging 20 patients.¹³ In the authors' experience, one of the more common indications for pediatric septoplasty is severe nasal obstruction because from 7% to 12% of children snore, but less than 1% of young children have clinical obstructive sleep apnea syndrome. Even then, the majority of cases are not due to septal deviation.¹⁵ Thus, it is important to remember that making

Evaluation of the patient

The child with chronic nasal obstruction is a common referral for the otolaryngologist, and it is the exception when the cause is limited to the nasal septum. Proper evaluation of the patient and treatment of any other properly identified causes will often negate the need for septoplasty, even in patients with a tortuous septum. The clinician must always keep in mind the factors noted in Box 1.

Fiberoptic endoscopy is the most effective method of initial evaluation and will reveal most of the

Indications for septoplasty

Absolute indications for performing a septoplasty in a pediatric patient include septal abscess, septal hematoma, severe deformity secondary to acute nasal fracture, dermoid cyst, and cleft lip nose (Fig. 1A, B). The latter two are often better addressed using an external rhinoplasty approach. Relative indications are limited to the patient with a severely deviated septum that is causing significant nasal airway obstruction or progressive distortion of the nasal dorsum.

Anatomy

The structure of the nasal septum is well known to otolaryngologists (Fig. 2). The pediatric septum differs in subtle ways from that of the adult. Growth of the nasal septum occurs in two phases, with the cartilaginous septum reaching adult size by the time the child is 2 years old, and further enlargement due to growth of the bony septum.¹⁶ The difference in the relative size of the quadrilateral cartilage as delineated by the osteocartilaginous suture lines in a 3-year-old patient and a

Surgical technique

In the senior author's practice, the surgical approach to the pediatric patient requiring surgery on the nasal septum follows a stepwise algorithm, beginning with the least invasive and most conservative approach. Box 2 summarizes some highlights and pitfalls (see later discussion) that the senior author has realized over a career of operating on children.

Summary

Performing a septoplasty on a pediatric patient is often viewed with fear by many practitioners. The main concern that causes hesitation is the potential for altering or stunting the growth of the nose or midface. Although the evidence pendulum appears to be swinging toward allowing the operation, which should not result in long-term sequelae if done using the proper techniques, it should still be approached with some trepidation.

The surgeon must always evaluate the child thoroughly to ensure

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Septorhinoplasty in children
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Growth of the face and jaws after resection of the septal cartilage in the rabbit
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The snout after resection of nasal septum in adult rabbits
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Facial growth effects of nasal septal cartilage resection in beagle pups
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Effects of nasal septal cartilage resections on young guinea pigs
Plast Reconstr Surg
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Experimental production of growth disturbance by using a caudally based vomerine flap in rabbits
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Early submucous resection of nasal septal cartilage. A pilot study in canine pups
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Corrective rhinoplasty before puberty: a long-term follow-up
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There are more references available in the full text version of this article.

Cited by (43)

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Adenotonsillectomy: The Nose, Nasopharynx, and Palate
2024, Otolaryngologic Clinics of North America
Anatomy of pediatric obstructive sleep apnea
2023, Operative Techniques in Otolaryngology - Head and Neck Surgery
Pediatric obstructive sleep apnea is most commonly caused by adenotonsillar hypertrophy, for which adenotonsillectomy remains one of the mainstays of treatment. For patients with persistent obstructive sleep apnea following adenotonsillectomy, or for patients in whom the adenoid and tonsils are not contributing to airway obstruction, individualized treatment is centered around identifying the site of obstruction. Obstruction can occur anywhere along the upper airway and is often multilevel. These sites can include the nasal cavity, nasopharynx, velum, oropharynx, tongue base, and/or supraglottis. Knowledge of this anatomy is essential.
Associations between skeletal discrepancies, breathing pattern, and upper airway obstruction in Class III malocclusions
2023, International Journal of Pediatric Otorhinolaryngology
To verify the associations between sagittal and vertical skeletal discrepancies, changes in upper airways, and breathing pattern in children and adolescents with Angle Class III and Class III subdivision malocclusions.
Eighty-five children and adolescents with a mean age of 9.5 ± 1.74 years were selected. Cephalometry assessed the sagittal relationship (AO-BO measurement), facial types (Ricketts VERT index), nasopharynx, and oropharynx. An otorhinolaryngologist analyzed the breathing pattern and upper airway obstruction during anamnesis, physical examination, anterior rhinoscopy, and nasofibroscopy. Medical records were also reviewed. For statistical analysis, ordinary one-way ANOVA, Kruskal-Wallis (Tukey's post-hoc), unpaired t-test, Pearson's correlation, chi-square, and Fisher's exact tests (p < 0.05) were used.
The nasopharyngeal cephalometric dimension and pharyngeal tonsil hypertrophy were associated, whereas the oropharyngeal cephalometric dimension and palatine tonsils hypertrophy were not. Sagittal discrepancies were associated with septum deviation, while facial type was associated with inferior turbinate and palatine tonsils hypertrophy. However, facial type was not associated with breathing pattern, septum deviation, and pharyngeal tonsils hypertrophy.
Sagittal discrepancies and type of malocclusion were not associated with breathing pattern and changes in upper airways, except for the severity of septum deviation and Class III malocclusions, which were associated with large sagittal discrepancies. Although the facial types analyzed presented signs of airway obstruction, the highest prevalence of inferior turbinate and palatine tonsils hypertrophy were found in patients with dolichofacial type.
Pediatric septoplasty and functional septorhinoplasty: A quality of life outcome study
2018, International Journal of Pediatric Otorhinolaryngology
This study assessed disease-specific quality-of-life outcomes among pediatric patients undergoing septoplasty or functional septorhinoplasty. The Nasal Obstruction Symptom Evaluation (NOSE) score was obtained pre- and post-operatively. Additional analyses determined whether demographics, nasal trauma, prior nasal surgery, or allergic rhinitis history affected NOSE scores.
Patients undergoing septoplasty or functional septorhinoplasty were evaluated prospectively at a tertiary children's hospital. NOSE scores were assessed pre- and post-operatively. Change in NOSE score was analyzed using the Wilcoxon Signed Rank test, while multiple regression analysis evaluated factors associated with NOSE score change.
136 patients (mean age 15.7 ± 2.1 years) were evaluated; 52 (38.2%) underwent septoplasty while 84 (61.8%) underwent functional septorhinoplasty. Mean follow-up was 3.6 ± 5.1 months. There was a statistically significant decrease in NOSE score from pre-operative septoplasty and functional septorhinoplasty: median = 75 to post-operative septoplasty: median = 20 (z = −5.9, p < 0.001) and functional septorhinoplasty: median = 15 (z = −7.9, p < 0.001). Gender, age, nasal trauma, prior nasal surgery, and allergic rhinitis did not have a significant effect on NOSE score change for either group. Additional surgery at the time of procedure was not a confounding variable in the relationship between surgery type and NOSE score. A NOSE Scale reliability analysis demonstrated high internal consistency with Cronbach's α of 0.83 across septoplasty and functional septorhinoplasty patients.
There was significant improvement in disease-specific quality-of-life in pediatric patients undergoing septoplasty or functional septorhinoplasty. Gender, nasal trauma, prior nasal surgery, and allergic rhinitis did not significantly affect NOSE scores in either group.
Pediatric septoplasty
2018, Operative Techniques in Otolaryngology - Head and Neck Surgery
Citation Excerpt :
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
Although septoplasty is routinely performed in the adult population, concerns regarding nasal and facial growth have restricted the 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, preoperative evaluation, and techniques of pediatric septoplasty including closed and open approaches. It also describes postoperative care and possible complications of pediatric septoplasty.
Effect of early correction of nasal septal deformity in unilateral cleft lip and palate on inferior turbinate hypertrophy and nasal patency
2018, International Journal of Pediatric Otorhinolaryngology
A relatively neglected aspect of cleft lip nasal deformity is the effect of septal deviation and inferior turbinate hypertrophy (ITH) on the functional airway. In particular, ITH in the noncleft side can be especially problematic, because it reduces the healthy nasal area, creating bilateral nasal obstruction that might affect the growth of the maxillofacial skeleton. Although these anatomic and functional changes are documented, few recommendations have been developed regarding the proper approach to ITH. The aim of the present study was to asses the ITH severity and determine the degree of nasal airway patency in patients who have undergone primary correction of the nasal septum during lip repair compared to patients operated on without primary septal correction.
The study population included two groups. One group consisted of twenty unilateral cleft lip palate UCLP patients who have previously undergone primary rhinoseptoplasty as part of their treatment plan. The control group consisted of twenty UCLP patients operated on without rhinoseptal correction.
The Nasal Obstructive Symptom Evaluation (NOSE) scale and nasal endoscopy were used to assess nasal obstruction.
The overall untreated group reported severe symptoms across all NOSE scale dimensions more frequently than children who have undergone primary rhinoseptoplasty. The difference was statistically significant for each dimensions (p < 0.05). The mean NOSE score for group A and group B was 21.4 ± 9.4 and 70.8 ± 17.2 respectively (p < 0.0001).
In group A turbinate size decreased significantly (p < 0.05) compared to pre-operative data.
Comparing the two groups a statistically significant difference in turbinate size was observed (p < 0.0001).
The results of the present study confirm that there is a significant degree of ITH and nasal airway dysfunction in patients with UCLP. Early septal repositioning during primary cleft lip repair results in a statistically significant reduction in IT size and improvement of nasal patency.

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Pediatric Septoplasty

Section snippets

Historical overview: animal studies

Historical overview: human studies

Prevalence

Evaluation of the patient

Indications for septoplasty

Anatomy

Surgical technique

Summary

Growth of the nose and the septorhinoplastic problem in youth

AMA Arch Otolaryngol

Septorhinoplasty in children

Otolaryngol Clin North Am

Growth of the face and jaws after resection of the septal cartilage in the rabbit

Am J Anat

The snout after resection of nasal septum in adult rabbits

Arch Otolaryngol

Facial growth effects of nasal septal cartilage resection in beagle pups

Effects of nasal septal cartilage resections on young guinea pigs

Plast Reconstr Surg

Experimental production of growth disturbance by using a caudally based vomerine flap in rabbits

Early submucous resection of nasal septal cartilage. A pilot study in canine pups

Arch Otolaryngol

Corrective rhinoplasty before puberty: a long-term follow-up

Plast Reconstr Surg