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Original Investigation |

Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate

Jonathan P. Massie, BS1; Christopher M. Runyan, MD, PhD1; Marleigh J. Stern, BA1; Michael Alperovich, MD1; Scott M. Rickert, MD2; Pradip R. Shetye, DDS1; David A. Staffenberg, MD1; Roberto L. Flores, MD1
[+] Author Affiliations
1Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, New York
2Department of Otolaryngology, New York University Langone Medical Center, New York, New York
JAMA Facial Plast Surg. 2016;18(5):347-353. doi:10.1001/jamafacial.2016.0404.
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Importance  Septal deviation commonly occurs in patients with cleft lip and palate (CLP); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood.

Objectives  To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction.

Design, Setting, and Participants  This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study.

Main Outcomes and Measures  Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified.

Results  Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = −0.61; P < .01).

Conclusions and Relevance  Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty.

Level of Evidence  NA.

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Figure 1.
Sample Cone-Beam Computed Tomographic Measurements Obtained for All Patients

A, Septal deviation is calculated as the mean distance of the right and left mucosal septum from midline (dashed red line). Yellow line indicates midline to right mucosal septum; green line, midline to left mucosal septum; blue line, mean septal deviation. B, Airway stenosis is measured as the smallest distance between the nasal septum and lateral nasal wall or adjacent turbinate (arrow). C, Perpendicular plate of the ethmoid bone angle is measured from the vertical plane. D, Vomer angle is measured from the vertical plane.

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Figure 2.
Measurements of Septal Deviation, Stenosis, and Bony Angular Deviation

Septal deviation, stenosis, and angular measurements were compared in patients with cleft lip and palate (CLP) vs controls (left) and in patients with unilateral vs bilateral CLP (right). Septal deviation and stenosis were measured at the anterior nasal spine (ANS), posterior nasal spine (PNS), ANS-PNS midpoint (MID), and point of maximal septal deviation (MSD). Bony septum angle measurements were performed from the vertical plane for the perpendicular plate of the ethmoid bone (PPE) and vomer at the point of maximal septal deviation.

aP < .01 compared with MID among patients with CLP.

bP < .05 compared with controls.

cP < .01 compared with controls.

dP < .001 compared with MID among patients with CLP.

eP < .001 compared with PNS among patients with CLP.

fP < .01 compared with patients with bilateral CLP.

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Figure 3.
Correlation Between Vomer Angle and Anterior Nasal Spine (ANS) Stenosis

The univariate Pearson product moment correlation coefficient identified from multivariable regression analysis (eTable in the Supplement) is depicted (regression line) between vomer angle and nasal stenosis at the ANS for patients with cleft lip and palate (CLP) and controls.

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