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Original Investigation |

Corrective Nasal Surgery in the Younger Patient ONLINE FIRST

Eelam Adil, MD, MBA1,2; Neerav Goyal, MD, MPH1; Fred G. Fedok, MD1
[+] Author Affiliations
1Section of Facial Plastic and Reconstructive Surgery, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey
2Department of Otology and Laryngology, Children’s Hospital Boston, Otolaryngology, Boston, Massachusetts
JAMA Facial Plast Surg. Published online February 06, 2014. doi:10.1001/jamafacial.2013.2302
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Importance  To describe clinical parameters for the management of the pediatric patient with nasal anatomical deformity or functional impairment.

Objectives  To review the authors’ experience with corrective nasal surgery in pediatric patients and make recommendations regarding indications for surgery and surgical techniques.

Design, Setting, and Participants  A retrospective medical chart review was performed for all male patients younger than 16 years and female patients younger than 14 years seen by the senior author (F.G.F.) at a tertiary referral center between August 1996 and August 2012. The database was searched for patients who underwent septoplasty or corrective nasal surgery by the senior author.

Exposures  Patients included in the study underwent either septoplasty or corrective nasal surgery by the senior author.

Main Outcomes and Measures  Age, indication for surgery, surgery performed, and last follow-up appointment was recorded for each patient. In addition, any complications or need for revision surgical or adjunct procedures were noted.

Results  Demographics and outcomes for 54 pediatric patients were included in the study. The most common indications for surgery were posttraumatic deformities (n = 36) and severe airway obstruction (n = 48). Fifteen patients with severe nasal airway obstruction did not have a documented history of trauma. The mean follow-up period was 646 days (approximately 21 months), with a range of 8 to 4062 days. Five patients underwent a staged procedure, and no patients underwent a revision procedure for unsatisfactory results.

Conclusions and Relevance  Children with nasal obstruction and deformity can safely undergo nasal corrective surgery prior to adolescence. Special considerations include preserving normal structures and the judicious use of grafts. The recommended approaches to managing the pediatric septoplasty and nasal surgery patient are described herein through a series of representative cases.

Level of Evidence  3.

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Figures

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Figure 1.
Case 1: A 10-Year-Old Girl Who Presented After Trauma to Her Nose Caused an Acute Saddle Deformity

A, B, and C, Preoperative clinical photographs depicting flattening and widening of upper and middle nasal vaults secondary to comminution of nasal bones and fracture of cartilaginous septum resulting in left airway obstruction and acute saddle deformity. D, E, and F, Six-month postoperative clinical photographs after surgical repair involving septoplasty, placement of bilateral spreader grafts, lateral osteotomies, and columellar strut. The left ear served as a donor site for cartilage grafts. (A and D, Frontal view; B and E, side view; C and F, base view.) G, Intraoperative photograph showing severe septal displacement into the left airway.

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Figure 2.
Case 2: A 14-Year-Old Boy Referred by a Pediatric Otolaryngologist for Nasal Obstruction and Correction of Severe Septal Deviation

A, B, and C, Preoperative clinical photographs depicting severe nasal deviation to the right and airway obstruction secondary to underlying septal deformity. D, E, and F, Eight-month postoperative clinical photographs after surgical repair involving septoplasty, placement of bilateral spreader grafts, and lateral osteotomies. (A and D, Frontal view; B and E, side view; C and F, base view.)

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Figure 3.
Surgical Management of Severely Deviated Septum Secondary to Vertical Fracture of Septal Cartilage

The technique incorporates the use of spreader grafts to “brace” the septum in correct position. A, Superior view of deviated middle vault and septum. B, Upper lateral cartilages have been divided from septum in order to be able to divide septum vertically at the apex of the angulated region. Although it is not always necessary to completely divide septum through its most superior portion, in this depiction, it is divided to allow maximal mobilization. C, Bilateral spreader grafts are sutured in place between upper lateral cartilages and septum. The spreader grafts will hold the septal segments in correct position and reconstitute the middle vault.

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Figure 4.
Surgical Management of Severely Deviated Septum Secondary to Horizontal Fracture or Deviation of Septal Cartilage at the Level of the Maxillary Crest

This technique is based on the removal of a narrow strip of redundant or buckled cartilage parallel and adjacent to the maxillary crest to allow the repositioning of the cartilage back on top of the crest with minimal cartilage resection. A, Septal spur or buckling of the septum adjacent to the maxillary crest. B, A #15 scalpel is used to excise the narrow strip of redundant or buckled cartilage parallel to and adjacent to the maxillary crest. C, The septum is then repositioned over the maxillary crest. If necessary, the deviated maxillary crest bone may be carefully osteotomized to allow it to be fractured back into a vertical midline position without removal of bone.

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