Portuguese Version

Year:  2002  Vol. 68   Ed. 3 - (5º)

Artigo Original

Pages: 320 to 323

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Septorhinoplasty in children

Author(s): José Victor Maniglia(1),
Fernando Drimel Molina(2),
Luciano Pereira Maniglia(3),
Claudia Pereira Maniglia(4)

Keywords: septoplasty, rhinosseptoplasty, rhinoplasty, children

Abstract:
Introdução: nasal septal deformity is one of the most important causes of respiratory obstruction in children, responsible for chronic rinossinusites, otites media, feeding difficulty and complications of oral breathers. Surgical correction should be performed, early in life, when indicated. Study design: clinical retrospective. Material and method: A series of 80 patients, between 4 and 14 years of age, on whom Septoplasty, Septorrinoplasty, Rhinoplasty associated with others surgical procedures, as adenoidectomy, adenotonsilectomy and turbinectomy is presented. Resultado: recurrence of septal deviation occurred in 4 cases, pyramid deviation in 4, sinechiae in 3, septal perforation in 1 and infection in 1. Conclusão: rinosseptoplasty can be safely performed early in life when indicated and combined surgical procedures should be realized at the same time.

INTRODUCTION

Although septum and nasal deviation is present in all races and in nearly all age ranges, it is more frequently diagnosed in young adults than in children. Its prevalence varies according to the age group.

Homeostasis or insufficiency of the stomathognatic system is markedly affected by the compromise and influences craniofacial growth and development processes.

According to Enlow1, craniofacial growth is the physical increase in size and volume, which is an objective quantitative and measurable phenomenon through visual inspection or cephalometric analysis. Facial development may be defined as a qualitative phenomenon characterized by the capacity to perform tasks that are progressively more complex and perfect, which can be assessed through breathing, mastication, swallowing and facial neuromuscular tests.

According to Cardim2, the development of nasomaxillary complex starts at 40 days of embryonic life, when the first centers of maxillary ossification are noticed bilaterally to the cartilaginous nasal capsule, followed by the expansion of the ossification to the other facial areas, making bone connections with other embryonic processes. The inter-maxillary suture is formed by the extension of the palatine processes towards the midline and the pre-maxillary septum ligament that, by joining the nasal septum to the pre-maxilla, will be extremely important to the pulling mechanism that the endochondral mechanism of the septum will apply to the bones and sutures of the middle facial third. After birth, as a result of the action of the functional matrix over the nasomaxillary complex, the nasal septum has the role of sustaining the nose and nasal own bones, but with no further influence over facial growth.

The curve of human growth, as advocated by Martins3, is characterized by quick fetal growth, with de-acceleration after birth, followed by a period of relatively slow but constant growth during childhood, acceleration during puberty and complete halt after epiphysis fusion.

Hinderer4 stated that there are 3 different periods of initial nasal development: the first 5 years are characterized by fast growth, followed by 5 years of slow growth and five more years of acceleration.

Growth and development of human face depend on the genetic project in 40% of the cases. Denominated intrinsic factors, they are located at the chondrocytes at molecular level, and they are found at the periphery of the cartilage. The remaining 60% are responsible for extrinsic factor abnormalities (anterior nasal spine, relation crest-maxillary vomer, lateral nose cartilage and nasal conchae hypertrophy)5.

The original growth and development plan may be modified at any time by the extra-somatic environment, which is more than true for the facial region, which does not depend on differentiation of gene maturation, but rather on their interaction in the environment.

Gray, in 19656, reported the occurrence of nasal septum deviation at birth and Cotlle, in 1951, demonstrated the presence of nasal septum deviation in children born from C-sections.

During childhood, facial traumas can happen but diagnosis of the septum and nasal bone position is not normally performed7.

Nasal deformity is one of the main causes of nasal obstruction and feeding difficulties in childhood, in addition to causing blockade of nasolachrymal ducts, rhinosinusitis episodes, repetitive otitis media and severe sequelae in mouth breathers.

According to Kirchner, in 1955,8 lateral displacement of newborns' nose is usually caused by either situation: 1) pre-natal, as a result of forces applied to the nose during the last months of pregnancy; or 2) during delivery.

Septal deformities occur in two ways: 1) anterior deformity of the septal cartilage, caused by direct trauma or pressure, at any age and in 4% of the births; 2) combined septal deformity, involving all components of the septum and nasal pyramid, caused by compression through the maxilla, by pressure that occurs during pregnancy or during birth (part of facial deformity)8.

In children, 42% of the nasal septa are normal, 27% are deviated , and 31% are twisted.

The indications for correction of nasal septum deformities are: 1) restore nasal function; 2) nasal allergy associated to previous trauma; 3) growth defect or concha hypertrophy; 4) psychical factors associated to deformity; 5) esthetical factor.

According to Ortiz-Monastério10, the results of corrective rhinoplasty performed at early age are comparable to those obtained after the end of growth.

The present study intended to present the experience in treating children with nasal septum or nasal pyramid deviation and to break with the misconcepts that corrective surgical procedures should be recommended only after 15 years of age in girls and 18 years in boys, which was in fact based on vague clinical observations and personal impressions, with no confirmation by well conducted comparative studies.

MATERIAL AND METHOD

We used a group of 80 patients, 54 (67.5%) were male and 26 (32.5%) were female subjects, aged 4 to 14 years, mean age of 11.6 years. They were retrospectively assessed from data collected between January 1994 and December 2000.

Patients were submitted to septoplasty, rhinoseptoplasty, rhinoplasty (correction of isolated deviations of nasal pyramid using lateral and median osteotomy) and associated procedures, such as adenoidectomy, adenotonsillectomy and intraturbinal cauterization of concha, if indicated, at the same surgical act.

The method used to correct the septum deviation was advocated by Metzenbaw12, with replacement of rectified bone and cartilage into the posterior space of the harvested flaps. Lateral and median osteotomy has always been performed in subjects who had pyramid deviation, isolated or associated to other septum deviations.

Patients were assessed post-operatively at 7, 30, 90 and 180 days.

RESULTS

Septoplasty was the procedure performed in 65 cases (81.2%), followed by rhinoseptoplasty in 11 cases (13.7%), and rhinoplasty in 4 cases (5%).

As to associated procedures, intraturbinal cauterization was performed in 25 cases (56.8%), followed by adenoidectomy in 15 cases (34%) and adenotonsillectomy in 4 cases (9%) (Table 1).

Table 1. List of surgical procedures and associated surgeries.

Septoplasty - 65 (81.2%)
Rhinoseptoplasty - 11 (13.8%)
Rhinoplasty - 4 (5%)
Total - 80 (100%)

The following complications were identified in 13 (16.25%) patients: 4 (5%) presented recurrence of deviation, and 2 of them were re-operated; nasal pyramid deviation in 4 (5%) cases; synechiae in 3 cases (3.75%); septal perforation in 1 case (1.25%), and infection in (1.25%) case. There were no cases of bleeding (Table 2).

Table 2. List of identified complications.

Recurrence of septum deviation - 4 (5%)
Nasal pyramid deviation - 4 (5%)
Synechiae - 3 (3.75%)
Septum perforation - 1 (1.25%)
Infection - 1 (1.25%)
Total - 13 (16.25%)

DISCUSSION

The topic of surgical correction of septum and nasal pyramid deformities in children is still very controversial, but there are studies that confirmed that conservative modifications of the nasal septum and performance of osteotomy did not compromise the growth in children. Moreover, information given in courses and personal communications encouraged our studying and correcting of these defects, diagnosed in children after the 4th year of life. However, we did not intend to assess craniofacial growth or development, nor to conclude that surgery did not affect them.

There are no doubts that children who have nasal obstruction regardless of etiology can develop severe sequelae and mouth breathing complications.

Most nasal septum deviations in children are found in the anterior region of the septum, and they may be occasionally located at the septal cartilage-vomer junction, which is less frequently associated with nasal pyramid deviation5. Some patients may also present hypertrophy associated to nasal concha, adenoid and pharyngeal tonsil.

Considering the existence of three distinct periods in the development of the nose4, we understand that the best age range for the indication of septum deformity correction is between 5 and 10 years of age, but it can also be performed in other age ranges.

Ortiz-Monasteiro10 presented a series of 44 patients aged 8 to 12 years, and 31 of them had unilateral lip cleft, 5 had bilateral lip cleft, 5 had nasal deviation caused by trauma, 2 had large noses associated to hemangioma and one had large nose of hereditary etiology, and they were submitted to rhinoseptoplasty and assessed by comparative analysis of photographs, cephalometry and facial anthropometric measures during a 5-8 year follow-up period, with minimal age of 15 years. The author concluded that nasal and facial growth were not affected when rhinoseptoplasty was indicated before 12 years of age, which can be performed in a safe and conservative fashion. The results of early surgeries are compared to those performed after growth10.

An important study was conducted by Murakami et al.11, using pig ears as models, showing that cartilage incisions should be complete on concave surfaces and, if performed on the convex side, what is technically more difficult, they should be made by removing triangular strips. Metzenbaw12 technique includes this principle and when it is associated to conservative procedure for replacement of bone and cartilage rectified fragments to occupy the spaces created by their removal, it may be finished with osteotomy. The author stated, in 1928, that septum deviation in children should be corrected as early as possible to restore nasal permeability and normal nasal development.

A number of techniques were reported by well conducted studies, referring to the development of unilateral and bilateral mucoperiosteal flaps, and there are no comparative study suggesting the superiority of one technique over the other.

The technique we used most of the time to correct anterior septum deviations is the one described by Metzenbaw 12, and when indicated, it can be associated to cartilage posterior deviation by horizontal or vertical incisions, as well as to correction of posterior bone deviations, which can be simultaneously performed with medial, lateral or oblique osteotomy in case of twisted nose13.

The occurrence of failures, especially in cases of twisted nose, should always be discussed with the family and, in our experience, 4 of the 11 operated cases (36%) produced unacceptable results.

According to Macnamara14, since human shape is entirely devoted to function, it is difficult to find beauty in a face affected by functional disorders, and they can be properly compensated by corrections in harmony, improving their performance by morphofunctional rehabilitation.

Correction of associated pathologies, such as nasal concha hypertrophy, performed with intraturbinal cauterization (using normal or high frequency cautery or other selected techniques), adenoidectomy or tonsillectomy should be performed in the same surgical moment.

Permeability of nasal fossa enables growth and development of masomaxillary complex and deformities should be corrected as early as possible.

CONCLUSION

Septum or nasal pyramid deviations in children should be corrected early to provide harmonic growth, preventing the severe sequelae found in mouth breathers.

Associated surgeries when indicated to correct other causes of respiratory obstruction in children, such as for example nasal concha, adenoid or tonsil hypertrophy, should be performed in the same surgical time.

REFERENCES

1. Enlow DH. Crescimento Facial. 3ª Ed. Porto Alegre: Artes Médicas; 1993. 553 p.
2. Cardim VLN. Crescimento craniofacial. In: Psillakis JM. Cirurgia Craniomaxilofacial: Osteotomias Estéticas da Face. Rio de Janeiro: MEDSI; 1987. p. 25-41.
3. Martins AM. Genética do crescimento. Clin Pediat. São Paulo;1995:19(1):8-12.
4. Hinderer KH. Fundamentals of anatomy and surgery of the nose. Brirmingham, Ala.: Aesculapius Publishing Co.; 1971.
5. Kohler NRW. Distúrbios miofuncionais: um estudo de revisão das causas etiológicas e das conseqüências sobre o processo de crescimento/desenvolvimento da face. [Monografia - Especialização em Desordens Miofuncionais] Universidade Camilo Castelo Branco, São Paulo, 1994, 108p.
6. Gray LP. Deviated nasal septum, incidence and etiology. Ann Otol Rhinol Laryngol 1978;87(3 Pt 3 Suppl 50):3-20.
7. Cottle HM. Concepts of Nasal Physiology as Related to Corrective Nasal Surgery. Archives of Otolaryngology 1958:29-36.
8. Kirchner J. Traumatic nasal deformity in the newborn. Arch Otolaryngol 1955;62:139-141.
9. Willemot J, Pirsig W. Indications, techniques and long-term results of surgery of the nasal pyramid and septum in children. Acta Otorhinolaryngol Belg 1984;38(4):427-32.
10. Ortiz-Monasterio F, Olmedo A. Corrective Rhinoplasty before Puberty: A Long-term Follow-up. Plast And Reconstr Surg 1981;68(3):381-390.
11. Murakami W, Wong L, Davidson J. Application of the biomedical behavior of cartilage to nasal septoplastic surgery. Laryngoscope 1982;92:300.
12. Metzenbaun M. Replacement of the lower end of the dislocated septal cartilage versus Submucous Resection of the Dislocated End of the Septal Cartilage. Archives Otolaryngol 1928;9:282.
13. Maniglia JV, Dafico SR, Simone LHV, Ferreira Filho PG, Maniglia PG, Maniglia LP, Maniglia CP. Rinosseptoplastia reparadora em criança. cap. 20 p. 218-225. In: Maniglia AJ, Maniglia JJ, Maniglia JV. Rinoplastia Estética - Funcional - Reconstrutora Ed. nº 01 - Rio de Janeiro: Revinter; 2001.
14. McNamara JA. Factors affecting the growth of the midface. Ann Arbor Michigan, University of Michigan, 1976.

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[1] Joint Professor, Head of the Discipline of Otorhinolaryngology, Department of Otorhinolaryngology and Head and Neck Surgery, Medical School, São José do Rio Preto. General Director, Medical School of São José do Rio Preto - FAMERP.
[2] Professor, Department of Otorhinolaryngology and Head and Neck Surgery, Medical School, São José do Rio Preto. Master studies under course, Medical School of São José do Rio Preto - FAMERP.
[3] Resident physician, Department of Otorhinolaryngology and Head and Neck Surgery, Medical School, São José do Rio Preto - FAMERP.
[4] Undergraduate, Medical School, São José do Rio Preto - FAMERP.

Study conducted at the Department of Otorhinolaryngology and Head and Neck Surgery, FAMERP.

Study presented at the XXX Congresso Brasileiro de Otorrinolaringologia, Natal, October 2000.

Address correspondence to: José Victor Maniglia - Rua Ondina, nº 45 - 15015-200 - São José do Rio Preto - SP - Fax (55 17)235.3366 - E-mail: maniglia@unorpnet.com.br

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