Keywords
nasal septum - face - growth and development
Introduction
Septoplasty in adults is a well-established surgery, but in children it is still a
matter of controversy. Some authors contraindicate surgery before 17 to 18 years of
age, because they think that early surgical intervention would influence the normal
growth of the nose; others indicate surgery based on the explanation that the sooner
septal deviation of a child is corrected, the greater chance of developing normal
breath and therefore a suitable facial growth.[1]
[2] The surgery has undergone technical changes since its introduction to minimize trauma
to the nasal structure, thus reducing the possible postoperative complications.[1] This study aims to present the experience of the Department of Otolaryngology, University
Hospital, in the surgical treatment of children with nasal septum deviation and debunk
the concept that septoplasty should only be performed after 17 to 18 years of age.
Materials and Methods
This longitudinal cohort study had a sample of 40 patients, 24 (60%) boys and 16 (40%)
girls, aged 4 to 12 years, with a mean age of 9 years, in the period from January
2005 to March 2012 ([Table 1]). Patients underwent septoplasty and associated procedures such as adenoidectomy,
tonsillectomy, and cauterization of inferior turbinate, when indicated, in the same
surgery. These were assessed clinically and through nasal endoscopy in the postoperative
period at 10, 30, and 60 days, and annually thereafter, with the longest follow-up
of 7 years.
Table 1
Patient characteristics (n = 40)
|
n (%)
|
|
Sex
Female
Male
Age at surgery (y)
4
5
6
7
8
9
10
11
|
16 (40%)
24 (60%)
3 (7.5%)
1 (2.5%)
5 (12.5%)
1 (2.5%)
4 (10%)
5 (12.5%)
5 (12.5%)
10 (25%)
|
|
12
|
6 (15%)
|
Surgical Technique
-
With the patient under general anesthesia, asepsis and antisepsis procedures are performed.
-
Initially, a topically sterile cotton ball soaked in adrenaline concentration of 1:2,000
is placed in both nostrils with the aim of promoting vasoconstriction. After this,
epinephrine solution is infiltrated at a concentration of 1:80,000 in the septal mucosa
of both nostrils.
-
A septal incision is performed on the left side, held at the mucocutaneous transition
at nasal vestibule.
-
The septal mucosa is detached in subperichondrial and subperiosteal bilaterally after
transfixation of the quadrangular cartilage.
-
Detachment is extended to the nasal floor bilaterally to facilitate the removal of
possible cartilaginous and bony deviations.
-
Cartilaginous and bony deviations are excised conservatively to preserve the growth
of the septal cartilage, thereby avoiding abnormalities in nasal growth.
-
Hemostasis is reviewed.
-
The initial incision is sutured.
-
Splints and nasal packing are not used at the end of surgery.
-
All steps are performed with the endoscope at 0 degrees.
Results
Forty patients underwent septoplasty; 39 (97.5%) of them had associated inferior turbinate
cauterization procedure, 20 (50%) patients had adenotonsillectomy, and 17 (42.5%)
adenoidectomy ([Table 2]).
Table 2
List of associated procedures
|
n (%)
|
|
Septoplasty
|
40 (100%)
|
|
Adenoidectomy
|
17 (42.5%)
|
|
Adenotonsillectomy
|
20 (50%)
|
|
Cauterization of nasal inferior turbinates
|
39 (97.5%)
|
There were no intraoperative complications in any of the operated cases. All patients
were evaluated by performing nasal dressings in 10, 30, and 60 days, observing possible
adhesions and recurrence of the deviation, septal perforation, infection, and nasal
deformity. After this period, annual follow-up was done with the maximum of 7 years.
None of the aforementioned complications were recorded during this monitoring period.
Discussion
There is controversy in the literature about the consequences of septoplasty for septal
deviation in children, and some studies have shown that when done early the procedure
brought benefits in the short and long term.[2] A study conducted with 80 patients aged between 4 and 14 years old who underwent
septoplasty (65 patients), rhinoplasty (11 patients), and rhinoplasty (4 patients)
showed postoperative complications in only 13 of these patients (not specifying the
surgery performed); the authors concluded that the benefits brought by these surgeries
outweigh the occurrence of these minimal complications.[2] Dispenza et al[3] stated that more important than the age of indication for the procedure is the degree
of nasal obstruction, placing it as an absolute indication, because nasal obstruction
during infancy disrupts the normal development of the angle of the skull base and
consequently the maxillofacial growth and may cause malocclusion and jaw protrusion
with bone deformities, confirmed even with anthropometric measurements. Others[4]
[5]
[6]
[7] also claimed that delay defect correction can bring negative effect on organ systems
that play a role in somatic and psychic development of the child including voice changes
and sleep disturbances, but speculated that in some situations monitoring should be
done for real indication for surgical treatment. A study performed with 44 patients
aged between 8 and 12 years old who underwent septal surgery (reconstructive rhinoplasty)
showed efficacy in relation to nasal obstruction and demonstrated that surgery when
performed conservatively does not harm the facial growth or promote nasal deformities.[8] In our study, all 40 patients were younger than 12 years old and underwent septoplasty
surgery early, avoiding development of deformities resulting from mouth breathing.
None of our patients had facial deformity at the first visit and none had nasal deformity
after surgery (maximum follow-up of 7 years).
Septoplasty can be performed safely without affecting the nasal and facial development
in appropriately selected patients, and delaying the procedure may cause asymmetry
and craniofacial anomalies.[9]
[10] There are caveats, however, that surgery can negatively influence the growth of
the nasal dorsum when done by an external approach and that before considering pediatric
nasal septum surgery, a thorough clinical examination should be performed for a correct
diagnosis and appropriate surgical indication.[9]
Research that showed convincingly that septoplasty in children causes nasal deformity
could not be found in the literature. Some studies even questioned the possibility
of the occurrence of these deformities; however, most studies, like ours, showed that
early surgery when indicated is beneficial.
Thus, the studies found in the literature,[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] whether anthropometric or clinical trials, corroborated our findings that septoplasty
in children allows appropriate craniofacial growth and development, prevents abnormalities
in somatic and psychic component of the patient, as well as demystifies the concept
that septoplasty should only be performed after the age of 17 to 18 years old.
Conclusion
The nasal septum deviation should be corrected early to provide a harmonious craniofacial
growth and appropriate child development, without the occurrence of nasal deformity.
