Surgical Correction of Caudal Septal Dislocation in Septoplasty and Septorhinoplasty

INTRODUCTION: Septal deviations are one of the most common causes of disordered nasal breathing. Specifically, caudal septal deviations represent a unique challenge. This portion of the nasal septum serves multiple functions regarding shape and support for nasal breathing and for facial aesthetics. The nasal surgeon is tasked with ensuring reduction, or total correction, of the offending deviation while maintaining adequate support and projection of the nasal tip 1) . Complicating matters is the caudal septum’s contribution to the internal nasal valve area and the attention that must be given to this critical area to improve nasal breathing (2) .


CORRECTION OF CAUDAL SEPTAL DISLOCATION
Wedging, Scoring, & Morselizing are generally recognized as one of the most conservative methods of managing the caudal septal deviation. Bowed caudal septum may also be corrected by using of Mustarde-type sutures. Ellis first described using cartilage manipulating techniques that many apply for prominent ears 6 . This technique can be effective for mild to moderate deviations. Stabilization of the repositioned caudal septum can also be done by way of a tongue ingroove technique. Kridel describes stabilizing the septum in a groove between the medial crura. Suture is used to secure the septum in the intracrural pocket (7) .Digman first described the use of batten grafting in 1956. Since that time multiple incarnations of this theme have been proposed by various authors (8)(9)(10) . For Septal reconstruction, moderate to severe caudal deviations may require more aggressive strategies. Complete resection of the cartilaginous septum with reconfiguration of an L-shaped strut has been termed extracorporeal septoplasty by King and Ashley in 1952 (11) . The cartilage is removed en-bloc and placed in the mucoperichondrial pocket and secured to the dorsal remnant with suture and at the anterior septal spine. Gubisch has followed over 2000 patients for the last two decades using the extracorporeal septoplasty with excellent result (12)(13) .

PATIENTS AND METHODS: Study Design and Setting:
A prospective, observational study was conducted on 50 patients (18 females and 32 males) who underwent nasal surgery (11 septoplasty, 39 septorhinoplasty). The study conducted in Center of Otolaryngology-Head and Neck surgery/ Sulaymaniyah Teaching Hospital and Azmar private hospital from 10 January 2018 to August 2018. Sampling Preoperatively patients were assessed for functional, aesthetic complaints. Analyzing the facial components. Internal examination of the nasal cavity was done. Nasal patency assessed by cotton wool test, Cottle test. Assessment of the caudal part of the septum was done and classified to mild, moderate and severe according to the ratio of deviated caudal septum into the nostril (mild=1/3 of the nostril, moderate=between 1/3 to 2/3, severe=more than 2/3). Nasal Obstruction Symptom Evaluation (NOSE) scale was provided to the patients and explained thoroughly. These informations were gathered and arranged during initial examination. Exclusion criteria: age group younger than 18 years old. Revision nasal surgery. Patients with allergic rhinitis. Enlarged inferior turbinates causing severe nasal obstruction. Operative procedures Septoplasty: Under general anesthesia with reverse Trendelenburg position( 30 o raised head ) Injecting the septum bilaterally with 1% lidocaine with 1:100,000 epinephrine. Once the patient is draped, a hemitransfixion incision is made along the free caudal edge using a number 15 blade. The incision is carried through the mucoperichondrium to expose the septal cartilage. Submucoperichondrial and submucoperiosteal flaps are elevated bilaterally using Freer elevator. the quadrilateral cartilage will separate from the bony septum posteriorly. By using turbinates scissors, cuts are made high (dorsally) and low (over the maxillary crest), and the deflected segment is removed. For the gently bowed caudal septum to one side, we used many techniques: like for example, scoring the deviated caudal septum from convex side and realign it to midline or excision a wedge piece from posterior part and moving the septum to midline. In some cases, we used suturing technique by creating a tunnel between the crura. After scoring or excising a wedge piece from posterior part we move the caudal septum inside the tunnel created and using a suture 4.0 vicryl, first the needle passed from the incision side from lateral to medial over the (caudal septal cartilage) forward through opposite side and again from medial to lateral through cartilage then full-thickness suturing was done then tied and repeated again inferiorly. In some cases we used angled converse scissors and we removed a small wedge of cartilage (about 2 to 3 mm) over the anterior nasal spine by blade no. 15 and this allow movement of the caudal strut to midline site over the anterior nasal spine which is shown in figure (1).When caudal septum is angulated; we transected the caudal strut along cephalocaudal vector, in this case the caudal septum becomes two segments. The excess length will allow the two segments to be overlapped and suture secured to one another to strengthen the caudal strut. Sometimes that junction is stabilized by using a harvested septal cartilage as a reinforcement batten graft, which is then sutured in

CORRECTION OF CAUDAL SEPTAL DISLOCATION
place on one side to bridge the two segments as shown in figure (2). Finally, the septal flaps from either side are quilted to one another with a running through-and-through 4-0 vicryl suture.

Septorhinoplasty:
Patient's position same as mentioned in septoplasty with same local anesthesia was used for infiltration inside nasal cavity. In columella, an incision(reverse V shape) was done with marginal incision along anterior margins of lateral crus. extraperichondrial and subperiosteal elevation of skin and muscles in one layer. Humpectomy was done according to each patient. Management of deviated bony pyramid via lateral and medial osteotomies. For septorhinoplasty; The deviated caudal septum is managed by either: Scoring or wedge excision and realignment of deviated caudal part was used for mild to moderate cases, Removing the deviated part and support of the dorsal and anterior by a L-strut graft as shown in Figure (3) or cutting through angulation line of the deviation with removing wedge piece from the septum to get the two parts edge to edge and enforce it by suturing together or with a batten graft at the concave side. Spreader grafts were taken from septal quadrilateral cartilage, the length of spreader grafts where selected according to the distance between the rhinion and the caudal end of the septum. A typical spreader graft will need to be approximately 1.5 -2.5 cm long, 3-5 mm wide, and 2-3 mm thick. We insert Spreader graft in between the septum and upper lateral cartilages. The graft was stitched to the dorsal septum with 5-0 polydioxanone(PDS) sutures. Reversed V shape columellar incision was closed by 6-0 nylon suture, marginal incisions was closed by using 3-0 Vicryl suture. In all cases bilateral internal nasal silastic splinting, anterior nasal packing, and external plaster of Paris were applied. Follow up: Nasal packing was removed after 24 hours. After 8 days internal nasal silastic splints, and external cast were removed, and the patients were assessed for the pain, bleeding, and nasal obstruction. Follow up were done after 6 months for all patients by nasal assessment including: we collected 50 patients' parameters which included: examination of type and severity of caudal dislocation, preoperative (NOSE) scale scores, perioperative techniques that were used during surgical procedures, postoperative nasal examination and correction degree of septal deviation and postoperative (NOSE) scale scores. The results were gathered and calculated by SPSS version 25.  FIG(3).shows the L-strut technique.

RESULTS:
For current study 50 patients' parameters were evaluated and the results were arranged as follow:
female to male ratio were (36%:64% ≈1:2). As shown in figure (5)  The severity of caudal dislocation distribution in patients who went through septoplasty was as shown in the table (2) below:      Technique. Corrected patients.

DISCUSSION:
The total number of patients in current study is 50 patients.32 of which were males while 18 were females with male: female ratio of (64%:36%). The age was ranged between 18 years to 39 years with the mean of (24.5±5.866) which is correlated with a study was done by S.Nadeem 14 in 2016,in Pakistan with male: female ratio of (69%:31%) and mean of age (37.1). In current study 28(56%) cases had deviated caudal septum to the left side, while 22(44%) cases were to the right side which is correlate with a study was done by Garcia 15 21 in 2013 in Canada in which they used a near like our technique to manage severe caudal dislocation. Using a relocation of caudal septum with notching maneuver with suturing the cartilage to the nasal spine with a good result as Akduman et al 22 . Use bony batten grafts with closed septoplasty and has a significant result regarding obstruction symptoms improvement, as Chung et al 23 .

CONCLUSION:
There are different approaches and techniques to be used in management of caudal septal dislocation with good results and according to each patient. The use of L-strut graft technique whenever is needed especially when facing severe caudal dislocation.

RECOMMENDATIONS:
Further studies and collecting a large number of cases are recommended for better assessment to demonstrate the effectiveness of these procedures in long term follow up .