extra-corporeal septoplasty in children

““بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم””

ويسر ”” صدرى لى اشرح ويسر رب صدرى لى اشرح ربأمرىأمرىى ى لل **

لسانى من عقدة لسانى واحلل من عقدة واحللقولى قولى يفقهوا صدق الله ”““يفقهوا

“العظيم

Extra-Corporeal Extra-Corporeal Septoplasty in ChildrenSeptoplasty in Children

Prof. Dr / Mahmoud El-Tarabishi.Prof. Dr / Mahmoud El-Tarabishi.

Ass.Prof. Dr / Waleed Farag EzzatAss.Prof. Dr / Waleed Farag Ezzat

LecturerLecturer Dr. / HOSSAM RABIE

ENT Department – Ain Shams UniversityENT Department – Ain Shams University

IntroductionIntroduction

The repair of nasal septal deformities in children is still controversial.

The main reason for these arguments is the possible risk of damaging to growing points during surgery.

malocclusion,

dental problems, facial deformities and pulmonary problems ( OSAS ).

Possible damaging to growing points with suspected midface disturbances . ( Freng &Haye 1985)

Multiple clinical human studies ECS safe as regard development of the nose and midface (Walker , Bejar ,El-Hakim 1993,1996, 2001).

Disturbed mid-face growth with Septoplasty still controversy (animal studies ,procedure, no good evidence from clinical studies ).

Our ObjectivesOur Objectives

First , to investigate the efficacy & to Standardize the Extracorporeal Septoplasty technique , through Open Approach in children .

Second ,short & long term follow up for relieve of nasal obstruction and effect on mid-face development.

MethodologyMethodology

• DuringDuring 2005/2006 2005/2006 in ENT dept, Ain Shams University in ENT dept, Ain Shams University 14 children , age 5-11 years old were selected according

Inclusion criteria :

-Chronic persistent nasal obstruction .

-Mouth breather at rest .

-Only due to deviated nasal septum .

Exclusion criteria :

•Congenital mid face abnormalities .

•Previous severe maxillofacial trauma .

•Other causes of nasal obstruction.

MethodologyMethodology

•All patients underwent :

•Clinical assessment & CT-PNS.

• ECS through open approach .

• Followed up-- average 4 yrs.

• Assessed for septal condition

nasal patency ,and

nasal growth parameters

( length , width, height ,and protrusion ) .

Walker et ,al 1993

Procedures & ResultsProcedures & Results

Open Rhinoplasty Open Rhinoplasty Approach .Approach .

- mid columellar, - mid columellar, and marginal and marginal incision.incision.

Procedures & ResultsProcedures & Results

DissectionDissection of the of the septum & septum & elevation of flaps elevation of flaps bilaterally . bilaterally .

septum septum delivered delivered externally for re-externally for re-shaping .shaping .

Procedures & ResultsProcedures & Results

Creating straight Creating straight septal plate .septal plate .

- excision & - excision & suturing.suturing.

- cross hatching.- cross hatching. - scoring .- scoring . - drill re-shaping.- drill re-shaping.

Procedures & ResultsProcedures & Results

Short ,small Short ,small cartilage .cartilage .

- - Prolene meshProlene mesh..

- PDS foil.- PDS foil.

- P P ethmoid .- P P ethmoid .

- conchal / tragal. - conchal / tragal.

Gubisch 2005

Procedures & ResultsProcedures & Results

Septal fixationSeptal fixation . .

- ULC ……U – shaped sutures .- ULC ……U – shaped sutures .

- nasal spine notch & hole .- nasal spine notch & hole .

Gubisch 2005

Procedures & ResultsProcedures & Results

Preventing Preventing complications .complications .

- Quilting sutures.- Quilting sutures.

- Haemostasis.- Haemostasis.

- Splinting (- Splinting (4wk4wk ). ).

Procedures & ResultsProcedures & Results

All patients after All patients after at least 3 years F Uat least 3 years F U & & showed satisfactory showed satisfactory clinical improvement clinical improvement regarding :regarding :

1 - nasal patency.1 - nasal patency.

2 - septal alignment .2 - septal alignment .

3 - cosmetic results .3 - cosmetic results .

Procedures & ResultsProcedures & Results

4 - Nasal growth4 - Nasal growth

we used we used anthropometricanthropometric measures for dorsal measures for dorsal

length , width , height & length , width , height &

protrusionprotrusion . . 11 cases11 cases were within were within

normal range + SDnormal range + SD . . 3 cases3 cases were 1-2 mm only were 1-2 mm only

below the norms - SDbelow the norms - SD

case

Gender

Age at opert

Age at end

Dorsal length Nasal width Nose height Tip protrusion -

Case Ref Case Ref Case Ref Case Ref

11M7.37.312.3424244.1 + 4.244.1 + 4.2303031.6 + 2.031.6 + 2.0454547.5 + 3.447.5 + 3.4161617.7 + 1.517.7 + 1.5

22M5.75.710.7373738.6 + 3.938.6 + 3.9313130.1 + 1.730.1 + 1.7434345.0 + 2.345.0 + 2.3171716.7 + 1.416.7 + 1.4

33F8.18.112.6454544.5 + 3.344.5 + 3.3282830.9 + 2.030.9 + 2.0464647.2 + 3.347.2 + 3.3161617.4 + 1.517.4 + 1.5

44M6.06.010.5404038.6 + 3.938.6 + 3.9292930.2 + 2.030.2 + 2.0474745.0 + 2.945.0 + 2.9151516.5 + 1.216.5 + 1.2

55F10.410.414.4424246.0 + 3.146.0 + 3.1343431.0 + 1.631.0 + 1.6444449.1 + 3.249.1 + 3.2161618.6 + 1.518.6 + 1.5

66M11.011.015494947.0 + 4.047.0 + 4.0383834.2 + 2.234.2 + 2.2535351.9 + 3.451.9 + 3.4191918.6 + 1.518.6 + 1.5

77M10.010.014414146.0 + 4.246.0 + 4.2353533.1 + 2.533.1 + 2.5484849.7 + 3.849.7 + 3.8171718.9 + 2.218.9 + 2.2

88M6.36.310393938.6 + 3.938.6 + 3.9303030.2 + 2.030.2 + 2.0474745.0 + 2.945.0 + 2.9171716.5 + 1.216.5 + 1.2

99M9.09.012.5464644.1 + 4.044.1 + 4.0323231.6 +2.031.6 +2.0494947.5 + 3.447.5 + 3.4161617.7 + 1.517.7 + 1.5

1010F9.29.212.5434344.0 + 3.344.0 + 3.3292930.9 + 2.030.9 + 2.0383837.2 + 3.337.2 + 3.3181817.4 + 1.517.4 + 1.5

1111M6.36.39.5383836.2 + 3.436.2 + 3.4282829.4 + 1.829.4 + 1.8404043.7 + 3.043.7 + 3.0161616.0 +1.416.0 +1.4

1212M5.05.08353534.2 + 3.034.2 + 3.0262628.8 + 1.5 28.8 + 1.5 393942.1 + 2.442.1 + 2.4141415.2 + 1.2 15.2 + 1.2

1313F7.17.110.1323236.4 + 3.236.4 + 3.2333329.6 + 1.929.6 + 1.9393944.5 + 3.044.5 + 3.0141416.6 + 1.316.6 + 1.3

1414M7.07.010424238.6 + 3.938.6 + 3.9292930.2 + 2.030.2 + 2.0444445.0 + 2.945.0 + 2.9151516.5 + 1.216.5 + 1.2

This table shows the results regarding nasal growth parameters compared to mean of * Farkas- white Caucasian Americans , * Zankle –central Europeans ,*Sforza – north Italians .

Walker et ,al 1993

• No reference anthropometric facial growth data for Egyptians .

•We have now proceeding research about mid face growth parameters in childhood in patients with chronic nasal obstruction vs normal children .

Discussion & ConclusionDiscussion & Conclusion

Discussion & ConclusionDiscussion & Conclusion

Why Septoplasty in young age ?- Disturbed mid-face growth with

Septoplasty still controversy (animal studies ,procedure, no good evidence from clinical studies ).

- Disturbed mid-facial growth will eventually happen with persistent nasal obstruction + Other serious complications ( OSAS – SIDS – P+).

Discussion & ConclusionDiscussion & Conclusion

Van Loosen and coworkers had shown in 1997 that the growth of the nasal septum decelerates remarkably after age 2 years and ,They also postulated that the septal cartilage reaches adult size by age 5years and that further growth occurs courtesy of the bony perpendicular plate.

Recent work from Brazil 2005 adds that there is histological evidence of a reduction in the rate of growth of the quadrilateral cartilage by age 5 years and that deceleration starts by age 8 years.

Discussion & ConclusionDiscussion & Conclusion

Walker , Bejar ,El-Hakim 1993,1996, 2001 -- international clinical trials investigating the effect of open ECS in children , provided evidence about procedure safety, reliability and harmless growth consequences .

And,

Lastly here our work although small sample size ( introducing

recent concept for the community ) .

Why ECS through Why ECS through open approach ?open approach ?

- Trauma --- marked septal deformities .- Deformities in the multiple levels.- Most reliable for long term results ( tissue

memory ) - It is considered conservative ( reconstruction,

perichondrium preserving , re-assembling of cartilage ).

Discussion & ConclusionDiscussion & Conclusion

Why ECS through Why ECS through open approach ?open approach ?- Easy correction of associated external deformities .

Discussion & ConclusionDiscussion & Conclusion

Nasal valve area .Nasal valve area .

- - spreader graft.spreader graft.

Caudal end short / irregularCaudal end short / irregular . .

- columellar strut.- columellar strut.

Dorsal irregularities .Dorsal irregularities . - overlay dorsal graft .- overlay dorsal graft .

In children(5-8) with severe DNS & In children(5-8) with severe DNS & persistent nasal obstructionpersistent nasal obstruction

We think that ECS was a We think that ECS was a safe ,reliable ,applicable procedure , safe ,reliable ,applicable procedure ,

which provides good results which provides good results regarding both Cosmotic & regarding both Cosmotic &

functional outcomesfunctional outcomes . .

Discussion & ConclusionDiscussion & Conclusion

Dr.HOSSAM RABIE