Surgical Atlas of PEDIATRIC OTOLARYNGOLOGY CHARLES D.

BLUESTONE, MD Eberly Professor of Pediatric Otolaryngology University of Pittsburgh School of Medicine Director, Department of Pediatric Otolaryngology Children s Hospital of Pittsburgh Pittsburgh, Pennsylvania RICHARD M. ROSENFELD, MD, MPH Professor of Clinical Otolaryngology SUNY Downstate Medical Center Director, Div ision of Pediatric Otolaryngology Department of Otolaryngology Long Island College Hospital and University Hospita l of Brooklyn Brooklyn, New York 2002 BC Decker Inc Hamilton London

E-mail: info@bcdecker.com Website: www.bcdecker.com 2002 Charles D. Bluestone and Richard M. Rosenfeld Printed in Canada CHAPTER 11 NASAL AND SEPTAL DEFORMITIES Jon B. Turk, MD William S. Crysdale, MD Pediatric nasal surgery is performed for functional, aesthetic, and reconstructi ve reasons. Contrary to certain widely held beliefs, nasal surgery can be perfor med safely at almost any age if appropriate cartilage-sparing and suture-control maneuvers are employed. Failure to treat symptomatic pathology because of concerns over interrupting fac ial growth can prolong functional and aesthetic problems. Whereas a healthy respect for facial growth c enters should accompany any otolaryngologic intervention in children, surgical c orrection of structural nasal obstruction and deforming injuries should not be deferred until t he late teen years. PRINCIPLES OF NASAL SURGERY Older teenagers (males age 16 years or older, females age 14 years or older) are treated no differently than adults because beyond this age there is very little significant facial skeletal growth. Adolescents being considered for aesthetic nasal surgery must also have psycholo gical and emotional factors addressed with both themselves and their families. Children younger than age 15 years should have surgery performed using the least destructive techniques to accomplish the surgical goal;

nasal and septal cartilage should be reshaped and repositioned rather than remov ed. Techniques that rely on sutures to reposition and control the nasal tip are ofte n performed through the external approach, and are especially useful in pediatric rhinoplasty, owing to their nondestructive nature and revers ibility. Bony osteotomies, when necessary, should be performed with small sharp osteotome s to minimize bone loss and trauma to surrounding tissues. The periosteum overlying the nasal bones should always be preserved to prevent c ollapse of the nasal bones with resultant pyriform aperture and internal nasal valve stenosis. Figure 11 1 The mucoperichondrium is incised with a No 11 scalpel blade. Computed tomography (CT) scanning is the preferred radiographic method for nasal pathology. Plain radiographs are not recommended because fractures and cartilaginous deformities are poorly visualized. In contra st, CT scans demonstrate bony and cartilaginous deformities and provide information on the orbit, facial bones, and paranasal sinuses. Although not every patient requires radiographic imaging for diagnosis, CT scans serve to document pathology, aid surgical planning, and survey adjacent structures. The otolaryngologist performing septal and nasal surgery should maintain a dedic ated septorhinoplasty tray with sharp rasps and osteotomes. A lightweight adjustable headlight with a halogen or xenon light source should be routinely worn because overhead lights are inadequate for intranasal visualizati on. Finally, a dry operative field is essential for all nasal procedures, which is b est accomplished by infiltrating the nose and septum with local anesthetic and vasoconstrictor 10-15 minutes before the start of surgery. CLOSED REDUCTION OF NASAL FRACTURE Closed reduction is a minimally invasive technique used to reduce simple lateral ly displaced nasal fractures within 2 weeks of the onset of injury. Closed reduction is ideally performed when swelling has subsided, but before fib rosis and bony union has begun. This window of opportunity is typically between 5-10 days following the injury. While it may be appropriate to wait several days to reduce a nasal fracture, the nose must be examined professionally prior to that time to detect septal hematoma. If a septal hematoma is diagnosed it should be incised and drained immediately (Figure 11 1), usually under general anesthesia. A septal quilting stitch is placed (Figures 11 2A and B) and nasal packs are inserted bilaterally. This may prevent more serious sequelae such as septal abscess and saddle nose deformity. Figure 11 2 A, A short Keith needle on a 4-0 plain gut suture is passed back and f orth through the septum. B, Final appearance of quilted septum. Indications Simple nasal fractures that produce lateral displacement of the nasal pyramid, w ithin 10 days after onset of injury. Closed reduction is not the treatment of choice when anterior-posterior (ie tele

scoping) injuries occur or when there are concomitant fractures of the nasal septum. Open reduction should be considered when the injury involves both cartilage and bone, is complicated or comminuted, or if treatment must be deferred beyond 2 weeks. Anesthetic Considerations Although closed reduction is a rapid and simple procedure and is often performed under local anesthesia in adults, deep intravenous sedation or mask general anesthesia are preferred for children. Deep intravenous sedation or general anesthesia makes the procedure painless for the patient, but also eliminates the need for local anesthesia infiltration which otherwise may distort the nose significantly. This allows for a safer, more comfortable, and more accurate procedure. Preparation Closed reduction of a nasal fracture under deep intravenous or general anesthesi a should only be performed in the operating room setting. This allows maximum control of the airway along with patient and operator comfort. The patient is positioned supine with his or her head towards the anesthesiologi st, and the surgeon (if right-handed) stands to the patient s right. A pediatric closed reduction tray and a small Frazier tip suction are prepared a s the anesthesiologist begins induction. Procedure Well wrung-out pledgets sprayed with oxymetazoline are gently inserted into the patient s nose after anesthesia induction is begun. No local anesthesia is injected into the nose so as to prevent distortion. A small Goldman displacer, or other blunt instrument such as the back of a knife handle, is gently inserted into the nostril on the side of the inwardly displaced fracture (ie, the side where the nasal bone is fractured towa rd the septum) (Figure 11 3A). The surgeon s contralateral hand is placed on the skin overlying the outwardly displaced fracture (ie, the side where the nasal bone is fractured away from the septum). Depending on which way the nose is fractured, the surgeon will rest the thumb or forefingers of the contralateral hand on the external surface of the patient s nose. With both the displacer and the contralateral thumb or fingers moving in unison, the surgeon performs a fluid two-part movement (Figure 11 3B): 1. A downward movement (towards the patient s toes) is used to distract the fractu red nasal bones. 2. A sideways movement is used to simultaneously outfracture the inwardly displa ced nasal bone and infracture the outwardly displaced nasal bone; a click is often heard as the nasal pyramid moves into proper position . While considerable force may be necessary to reposition the fractured segments, the operator should be careful not to use so much force as to fracture or displace the nasal septum or upper lateral cartilages. By carefully inserting, manipulating, and withdrawing the Goldman displacer, muc osal laceration can be avoided and the procedure remains essentially bloodless. A nasal splint is then applied to the newly aligned nasal bones; intranasal pack ing is utilized only if there has been significant bleeding, which is extremely rare if closed reduction has been performed correctly. Postoperative Care If utilized, nasal packing is removed on the first postoperative day. Ice packs over the eyes are recommended for the first 48 hours. The nasal splint can be removed on the seventh postoperative day.

Gentle nasal exercises are begun in order to maintain bony alignment. These are accomplished by having the patient (or a parent) gently squeeze the na sal bones together a few times a day for the first seven days after the splint comes off. Pressure should be light, and the patient should not experience pain during this maneuver. The patient may resume light aerobic activity after 2 weeks, running and jumping at 4 weeks, and has no restrictions after 6 weeks. Figure 11 3 A, A small displacer is introduced into the nose on the side of the me dially displaced fracture, while fingers from the contralateral hand are placed on the side of the laterally displaced fractur e. B, After distracting the fractured segments (vertical arrow), gentle pressure is used to reduce the fracture (horizontal arr ow). Complications Complications following closed reduction are exceedingly rare. Inadequate fracture reduction may occur, and can be corrected with an open reduc tion performed at least 3 months after the failed closed reduction. Iatrogenic cartilage displacement is a rare complication, which is best avoided by judicious use of force and by proper instrument placement during closed reduction. SEPTOPLASTY Septoplasty eliminates nasal septal pathology interfering with normal nasal func tion. Most children with nasal septal pathology have nasal obstruction, which is a nonspecific and common complaint. The differential diagnosis of pedia tric nasal obstruction also includes sinusitis, allergic rhinitis, and adenoid hyperplasia, which may coexist with a septal problem. In addition to ant erior rhinoscopy, the diagnostic evaluation may require rhinometry, flexible endoscopy, or imaging studies to determine the etiology of nasal obstru ction. Septoplasty can either be completed using an internal approach or an external ap proach. The internal approach offers low morbidity, but is suitable only for pathology limited to the posterior inferior aspect of the nasal septum. The external approach has higher morbidity, but facilitates primary or revision surgery for all types of septal pathology, including large cartilagi nous defects (ie, necrosis after a septal abscess). INTERNAL APPROACH FOR SEPTOPLASTY Indications Nasal obstruction caused by septal pathology posterior and inferior to a line fr om the anterior nasal spine to the caudal aspect of the nasal bones (Figures 11 4A and B). To facilitate access to the nasal cavity when completing other nasal surgery (ie, polypectomy, endoscopic sinus surgery). Figure 11 4 A, The stippled area represents the location of the septal pathology. Note that it is posterior to a line joining the anterior nasal spine and the anterior aspect of the nasal bones. B, The view of septal pathology with anterior rhinoscopy. QC = Quadrilateral cartilage

Contraindications Mucosal disease such as allergic rhinitis. Systemic disease that places the patient at significant risk from general anesth esia. Anesthetic Considerations General anesthesia with a cuffed oral endotracheal tube stabilized on the chin o f the supine patient. The anesthetic machine is on the patient s left side to permit the surgeon (may be opposite if surgeon left handed) to stand on the patient s right side. Preparation The head is placed on a ring for stability, and a small roll is under the should ers to achieve a neutral position. The surgeon wears a headlight to facilitate visualization. Pledgets soaked in oxymetazoline solution are placed in both sides of the nasal cavity. Procedure The membranous septum and the submucoperichondrial layer of the anterior aspect of the quadrilateral cartilage (QC) are infiltrated with 5-10 mL of 1% lidocaine with 1:200,000 epinephrine solution using a 25-gauge nee dle. Using a No 15 scalpel blade, a right hemi-transfixion incision is used to expose the caudal end of the QC. The incision is made from anterior to posterior to avoid damaging the alar rim (Figure 11 5). Figure 11 5 Completing the right hemi-transfixion incision. On the concave side of the nasal septum, the mucoperichondrium is dissected back 4-5 mm from the edge of the QC using Converse scissors (Figure 11 6). A Beaver blade is used to gently incise the perichondrium layer; th e incision area is rubbed with an applicator stick to gain access to the exact plane beneath the perichondrium for further dissection. The mucoperichondrium is dissected with a Freer elevator (Figure 11 7) posteriorly and inferiorly until the anterior aspect of the vomer and the junction with the nasal crest of the maxilla is exposed. Dissection is now compl eted in a more measured fashion as one proceeds past the junction of the QC with the nasal crest of the maxilla to the floor of the nose. Using the Freer elevator or a Beaver blade on a long scalpel handle, an incision is made in the inferior aspect of the QC parallel to, but 5-6 mm from, the junction of the QC with the nasal crest of the maxilla. This incision must not extend anteriorly to the anterior nasal spine. This strip of cartilage is mobilized and ideally removed without damaging the mucous membra ne on the opposite side of the septum (the occurrence of a linear tear in the mucous membrane on the convex side of the septum is not problematic as this will now serve as the drainage site). The Freer elevator is inserted from the concave side into the subperichondrial a rea on the convex side; the mucous membrane on the convex side is elevated off the QC and the vomer as required, permitting removal of all areas that are significantly off the midline. The QC is not disarticulated from the ethmoid plate; in fact, there is as little dissection superiorly as possible. To preserve the integrity of the dorsal strut, no cartilage is removed anterior to a line from the anterior nasal

spine to the nasal bones. When excision of cartilage and bone (Figure 11 8) is complete, the hemi-transfixio n incision is closed with 3 or 4 interrupted stitches of absorbable suture (4-0 chromic catgut). The septum is usually quilted using absorbable suture (4-0 plain catgut) mounted on miniature Keith needles: 1. The suture has a needle at each end; one needle is cut off, and a knotis plac ed in the suture close to that end. 2. The remaining needle is driven back and forth through the septum starting 2-3 cm from the anterior naris and working anteriorly. 3. The quilting is continued for about six passes of the needle. The tension on th e suture is maintained by placing a knot when the quilting has been completed. Occasionally, there will be persistent bleeding. A small amount of Vaseline gauz e packing is inserted to achieve hemostasis. Postoperative Care Packing, if used, is removed the next morning. The patient is seen 1 week later to ensure that a septal hematoma has not occurr ed. The family is cautioned at the time of discharge that normal activity can be res umed 2 weeks after surgery. Figure 11 6 Dissecting the perichondrium back in a posterior direction. Figure 11 7 Using the Freer elevator to carry the dissection below the perichondri um more posteriorly. Figure 11 8 The view after removing adequate amounts of cartilage and bone. EXTERNAL APPROACH FOR SEPTOPLASTY The external approach for septoplasty allows a wide variety of techniques to be employed based on the type of septal deformity: If the pathology is posterior, excision of cartilage only can be utilized (the i ndication for the external approach has been the rhinoplasty part of the procedure). If the pathology is anterior, the posterior aspect of the QC can be used as a fr ee graft to replace the area that is crucial to the support of the nose and cannot be excised. This procedure is described below. If the case is a revision surgery, only fragments of cartilage may remain and ma y need to be filleted and sewn together to make a large enough free graft to be reinserted to provide mid-third support. If the cartilage is missing (the situation after a nasal septal abscess), endoge nous cartilage from the rib (first choice) or auricle can be used to create a free graft for insertion. The versatility of this approach is offset by increased morbidity and complexity of postoperative care (see below). Late complications, such as stitch granuloma, are more common because a nonabsorbable suture is used to fix the free graft in place. Moreover, salvage surgery can be challenging if further trauma to the nose occurs. Lastly, the correct insertion of a septal free graft is a difficult procedure to master if nasal surgery is done only occasionally. Indications

Anterior septal pathology interfering with nasal valve function; the deformity i s caudal to a line from the anterior nasal spine to the nasal bones (Figures 11 9 and 11 10). Posterior septal pathology when an external approach is needed for a coexisting problem, such as an asymmetric nasal deformity in a cleft lip or palate patient. Revision septoplasty. Contraindications Mucosal disease significantly interfering with nasal function. Systemic disease putting the patient at significant risk from general anesthesia . Lack of parental insight as to degree of septal pathology requiring this type of operative approach. Anesthetic Considerations and Preparation General anesthesia is required with a cuffed oral endotracheal tube stabilized on the chin of the supine patient. Pledgets soaked in oxymetazoline solution are placed in both sides of the nasal cavity. The anesthetic machine is on the patient s left side to permit the surgeon (if right-handed) to stand on the patient s right side.

Nasal and Septal Deformities 269 The patient s head is placed on a ring for stability, and a small roll is placed under the shoulders to achieve a neutral position. The surgeon wears a headlight to facilitate visualization. Figure 11 9 Gentle thumb pressure readily reveals anterior nasal septal pathology. Figure 11 10 Location of the septal pathology (stippled area) obstructing the nasal valve and anterior to a line from the nasal bones to the anterior nasal spine. QC = Quadrilateral cartilage

270 Surgical Atlas of Pediatric Otolaryngology Procedure Figure 11 11 The location and form of the transcolumellar incision. The face is prepped and a towel is wrapped tightly about the head just above the eyebrows to facilitate holding a miniature Aufricht retractor in place when the nose has been decorticated. A full body drape is applied. The soft tissues of the nose are injected with 1% lidocaine and 1:200,000 epinephrine solution. More solution is injected in the membranous septum, beneath the anterior aspect of the perichondrium of the QC, and in the pyriform aperture area if medial and lateral osteotomies are to be completed. Usually, about 10 mL are injected. The transcolumellar incision is drawn on the skin with a reverse gull wing silhouette to minimize the impact of any scar retraction (Figure 11 11). The incision is placed outside of the feet of the medial crura so that the crura base is undisturbed. Rim incisions are made with a No 15 blade 1-2 mm inside the nostril sill, from the apex of the external naris of the nostril to the lateral aspect of the transcolumellar incision (Figure 11 12). Converse scissors are used through the right rim incision to create a plane of dissection outside the medial crura towards the left rim incision (Figure 11 13): 1. The tips of the scissors are pushed through the left rim incision. 2. Next, through the right rim incision, dissection is carried up over the left dome area. 3. Then, through the left rim incision, dissection is carried over the right dome area. 4. Lastly, through the right rim incision, the skin is undermined inferiorly beyond the transcolumellar incision.

Nasal and Septal Deformities 271 Figure 11 12 Completing the right rim incision. Figure 11 13 Using the Converse scissors to dissect across the columella external to the medial crura into the left rim incision.

272 Surgical Atlas of Pediatric Otolaryngology Figure 11 14 The No 11 blade is utilized to complete the transcolumellar incision. The transcolumellar incision is completed using a No 11 blade held at right angles to the skin (Figure 11 14) using a sawing motion. Only 2 mm of the blade tip are inserted to minimize any damage to the underlying medial crura. The rim incisions are then advanced on each side along the caudal border of the lateral crura. For this maneuver, it is crucial that an assistant apply counter traction to the dome of the lower lateral cartilage using a skin hook (Figure 11 15). Once the rim incisions are of adequate length, dissection is carried over the domes until the upper lateral cartilages (ULCs) are encountered. Dissection is then carried superiorly in the midline over the ULCs and nasal bones creating a pocket in which the miniature Aufricht retractor can be inserted. The retractor is inserted to hold the skin out of the surgical field, and is stabilized on the towel above the eyebrows with a Kelly clamp. Next, the operator and assistant each pick up the medial crura with a Brown forceps. The operator divides the medial crura with a Beaver blade, cutting through the membranous septum until the caudal end of the QC is encountered and delineated down to the level of the anterior nasal spine (Figure 11 16). Gordon hooks are hung on the medial crura to keep them out of the surgical field. Converse scissors are used to begin the dissection under the mucous membrane on the concave side of the nasal septum. It is important that this initial dissection be 4-5 mm from the attachment of the ULCs to the QC. A Beaver blade is used to gently incise the perichondrium, and the incision is rubbed with an applicator stick so the proper plane is entered with the Freer elevator.

Nasal and Septal Deformities 273 Figure 11 15 The lower lateral cartilages are exposed with advancing rim incisions. Figure 11 16 The caudal strut of the quadrilateral cartilage is exposed after dividing tissue between the medial crura.

274 Surgical Atlas of Pediatric Otolaryngology Dissection will be limited because of the attachment of the ULCs to the QC. This attachment is divided under direct vision in a progressive fashion with a Beaver blade until the nasal bones are encountered. Dissection can now be carried posteriorly until the vomer is encountered; superiorly until the junction of the ethmoid plate and the undersurface of the nasal bones is reached; and inferiorly to the floor of the nose from the anterior nasal spine to beyond the juncture with the vomer bone. Ideally, this is accomplished while keeping the mucous membrane intact. Returning to the anterior aspect of the QC, a Converse scissors elevates the mucous membrane on the convex side of the septum away from the edge of the dorsal strut, again remaining 4-5 mm from the attachment of the ULCs with the QC. Dissection will be facilitated by the progressive release of the ULCs from the QC. Care must be taken when going around the septal spur towards the nasal floor, because the QC must usually be dislocated from the nasal crest of the maxilla towards the concave side of the nose to permit adequate access. Again, the mucoperichondrium is elevated off the entire QC to the undersurface of the nasal bones, onto the perpendicular plate of the ethmoid, and onto the vomer bone. The connective tissue at the junctions of the QC with nasal crest of the maxilla, the vomer, the perpendicular plate of the ethmoid, and the undersurface of the nasal bones are divided using the Freer elevator. Particular attention must be paid to the fibrous bands attaching the QC to the anterior spine and these may need to be divided with a Beaver blade. The QC can now be removed in its entirety (Figure 11 17). The QC is then kept moist in sterile saline until remodeling. Bone off the midline is now removed from the vomer and the nasal crest of the maxilla, while maintaining the perpendicular plate of the ethmoid intact. The upper surface of the anterior spine is trimmed to take off any irregular spicules of bone, but caution is exercised to not remove any significa nt amount of bone in this area. The inferior fixation suture (4-0 Mersilene) to be used later is placed through the anterior nasal spine (Figure 11 18): 1. With a firm, rotatory motion, an 18-gauge needle is driven in the midline from the anterior-inferior face of the anterior nasal spine up to the superior aspect. 2. The needle is used to guide the suture needle through the bone. 3. Care is taken to place the first knot (a double throw) on the upper surface of the anterior nasal spine exactly in the midline. 4. Two (single throw) knots secure this suture position. This suture is now put aside for future use. The distance from the anterior nasal spine to the nasal bones is measured with surgical calipers (Figure 11 19). This distance has varied from 1933 mm in 85 patients (aged 4 to 16 years) for whom data are available.

Nasal and Septal Deformities 275 Figure 11 17 The entire quadrilateral cartilage removed intact; the instrument points to a fracture line in the anterior aspect.

Figure 11 18 A nonabsorbable suture is placed through the anterior nasal spine. Figure 11 19 Surgical calipers measure distance from the anterior nasal spine to the nasal bones.

276 Surgical Atlas of Pediatric Otolaryngology Figure 11 20 The distance determined by the surgical calipers is transferred to the paper template. The template for the free graft is now made: 1. The QC is placed on a paper drape and the outline of the dorsal strut and the caudal strut is traced past the approximate junction with the anterior nasal spine. 2. One end of the surgical calipers (set at the distance determined from the anterior nasal spine to the nasal bones) is placed on the approximate position where the QC articulates with anterior nasal spine. The other end then determines where the free graft will meet the nasal bones (Figure 11 20). 3. A notch is drawn into the template (Figure 11 21), as this will be the part of the free graft that fits under the nasal bones. 4. Finally, one end of the calipers is placed on the paper where the nasal bones meet the free graft, and the other end is used to draw an arc in the template so that the position of the inferior fixation suture can be altered as required when one completes the sagittal swing maneuver. The template is now cut out of the paper drape. The QC is now remodeled to create the free graft. The QC is examined and the template is positioned on it to determine the best part to use, ideally the straightest and strongest area (Figure 11 22). The anterior pathology is trimmed away, saving the excised cartilage for possible later use (ie dorsal graft, columellar strut graft, tip graft, etc). With the template as a guide, a No 15 blade is used to carve out the free graft (Figure 11 23).

Nasal and Septal Deformities 277 Figure 11 21 The completed drawing for the free graft. (A) indicates where the free graft will be attached to anterior nasal spine. (B) is where the free graft will meet the nasal bones. Figure 11 22 The cut out paper template lying on the posterior aspect of the excised quadrilateral cartilage. Figure 11 23 The finished cartilage free graft.

278 Surgical Atlas of Pediatric Otolaryngology Figure 11 24 The free graft being sewn to the upper end of the upper lateral cartilages. The free graft is placed between the mucous membrane flaps with the notch under the nasal bones. Two interrupted sutures of the 4-0 Mersilene are placed through the ULCs and the edge of the free graft 1 and 3 mm from the nasal bones (Figure 11 24). The first knot of each suture is a double throw, as this will maintain tension until the second knot (a single throw) is placed and tightened. The skin of the nose is loosely draped in its normal position. Through the incision, the free graft is grasped in Brown forceps and rotated forward in the sagittal plane (the sagittal plane swing maneuver) until the correct support of the supratip region is obtained. The suture inserted earlier at the anterior nasal spine is used to fix the free graft in place (Figure 11 25). The first knot receives a double throw, and subsequent throws are single. When in doubt, fix the free graft too far in the anterior position as the septal angle area of the free graft can always be shaved down to the correct level. Using Keith needles, two transfixion sutures of 2-0 chromic catgut are placed through the free graft for additional stability (Figure 11 26). If the nasal bridge is asymmetric, medial and lateral osteotomies are completed at this time. For the medial osteotomies, the osteotome is placed by direct vision so that it engages the nasal bones but misses the upper fixation sutures. Medial and lateral osteotomies have been completed in 20% of 169 patients (mean age 12 years, youngest age 6 years) that have had the free graft procedure during the past 14 years.

Nasal and Septal Deformities 279 Figure 11 25 The inferior aspect of the graft being fixed to the anterior nasal spine following the sagittal plane swing maneuver. Figure 11 26 A transfixion suture further stabilizes the free graft position.

280 Surgical Atlas of Pediatric Otolaryngology Other rhinoplasty-type maneuvers (see below) tip grafts, dorsal grafts, ULC augmentation, etc) are completed at this time. The lower lateral cartilages are sutured back together with interrupted Vicryl sutures. The skin edges of the columellar incision are gently opposed with 5-7 interrupted sutures of 5-0 Prolene; it is important that these are not tight so that they can be easily removed. The rim incisions from their lateral extent to the midline are closed with interrupted sutures of 4-0 chromic catgut. A drainage incision approximately 1 cm in length is made in the inferior aspect of the nasal septum, 2-3 cm posterior to the anterior nasal spine; any accumulated blood is suctioned. Two strips of Vaseline gauze are inserted into each side of the nose, taking care to not pack the nose tightly as pain will result. An overlying adhesive dressing is now applied. A premanufactured splint is also applied to the nose if medial and lateral osteotomies were done. A moustache dressing is used for 2 days to catch any material that seeps from the nose. Postoperative Care The nasal packing is removed early in the morning 2 days following surgery, and the patient is discharged from hospital later the same day. The parent is instructed to apply antibiotic ointment to the columellar incision area twice each day until dressing removal. Nasal packs remain in place for 2 days, during which time the patient is hospitalized. Sutures must be removed from the columellar incision after surgery, which may very occasionally require a general anesthesia in young children. Further office visits are needed at 1 and 3 months postoperative ly to ensure satisfactory healing. At the time of discharge, the parents are instructed to call or return to the hospital if there is any fever, increased facial pain or swelling, or increased difficulty breathing through the nose. All of the latter may indicate the development of a postoperative infection. The overlying adhesive dressing and cast are removed 7 to 8 days following surgery. The patient remains at home until this visit and returns to school the Monday after this visit. Full activities can be resumed 1 month after surgery. Special Considerations Completing a reduction rhinoplasty at the same time that a free graft procedure is done is a technically difficult and high-risk procedure. Therefore, the patient and family are warned that a second procedure may be required at some time in the future if such a goal is appropriate. Postoperative nasal airflow studies are ideally completed 1 year following surgery. Ongoing follow-up with respect to the appearance and subsequent growth

of the nose is very much dependent on the age of the child at the time of surgery. Patients may be safely discharged from care at age 16 years.

Nasal and Septal Deformities 281 RHINOPLASTY Although often carrying a cosmetic connotation, rhinoplasty can also be performed for reconstructive and functional reasons. Open reduction of nasal fractures, the correction of dorsal septal deformities, and additive or reductive changes to the nasal framework may all be considered forms of rhinoplasty. As noted above, rhinoplasty can be performed at any age if conservative techniques are utilized. Surgery for strictly aesthetic purposes, however, should not be performed prior to age 15 years. Rhinoplasty may be performed via an endonasal approach or a transcolumellar incision (external or open approach), each method offering specific advantages and disadvantages (Table 11 1). When functional and cosmetic deformities coexist, techniques that simultaneously address the septum and external nasal framework may be combined to offer a singlestage return to form and function. Finally, because of its central location on the face, an aesthetically displeasing nose can be the source of much emotional and psychological discomfort for the teenage patient. Indications Reduction of a complicated nasal fracture (ie, involving both bony and cartilaginous structures or one that occurs in primarily an anterior-posterior direction). Reduction of a nasal fracture not initially treated or inadequately reduced by closed techniques. In these cases, rhinoplasty should be deferred at least 3 months from the time of original injury or failed closed reduction. Simultaneous functional and cosmetic repair of a traumatically or congenitally deformed nose (see also External Approach for Septoplasty-Indications). Alteration of an aesthetically displeasing nose. Table 11 1 Endonasal vs. external approach for rhinoplasty Approach Advantages Disadvantages Endonasal Allows better intraoperative visualization of final result Preferred for simple tip maneuvers or if no tip surgery is necessary No visible scar More difficult to judge symmetry during tip maneuvers Cannot address or reconstruct dorsal septum, if affected External Allows more precise tip surgery Affords excellent access to the dorsal septum, if affected Less destructive to existing nasal support mechanisms

 Potentially visible external scar Difficult to judge or visualize final result Slightly more time consuming

282 Surgical Atlas of Pediatric Otolaryngology Anesthetic Considerations All pediatric rhinoplasty surgery is performed under general endotracheal anesthesia to ensure maximal airway control and safety. Local anesthesia consisting of 1% lidocaine with 1:100,000 epinephrine is utilized to ensure a dry operative field and to diminish the requirements for general anesthesia. If using general anesthesia with local infiltration, there is no reason to use topical cocaine and this practice has been abandoned. Preparation The patient is positioned as for closed reduction. A lightweight headlight with halogen light source and 2.5x surgical loupes are used. Following intubation, a throat pack is fashioned by tying a piece of tie from a surgical mask around the sponge portion of a no detergent scrub brush. The pack is inserted transorally into the oropharynx to prevent blood from entering the trachea or esophagus, and to help to avoid postoperative aspiration or nausea. Procedure Two approaches are described: endonasal and external. No 1. Endonasal approach for rhinoplasty Surgical exposure Well wrung-out cotton pledgets sprayed with oxymetazoline are inserted into the nose with bayonet forceps. If the septum is also going to be addressed, it is infiltrated with local anesthesia. Further injections of local anesthesia are made at the planned incision sites and along the nasomaxillary groove and nasal dorsum. After allowing 10-15 minutes for vasoconstriction, a hemi-transfixion incision is made with a No 11 blade (Figure 11 27). If concomitant septoplasty is to be performed (see section on septoplasty), it is addressed at this point of the operation. A contralateral hemi-transfixion incision is made after septoplasty is complete (if performed), and the two incisions are connected with a fine blunt scissors. The resulting transfixion incision crosses the midline, but is not carried all the way down to the anterior nasal spine. Intercartilaginous incisions are made bilaterally with the No 15 blade, remaining close to the scrolled edge of the upper lateral cartilage (Figure 11 28). A fine blunt scissors is inserted into the intercartilaginous incision and spread three times until a pop is felt (fibers connecting the upper and lower lateral cartilages).

A slightly heavier scissors (small Metzenbaum) is introduced through the incision, and with the contralateral hand pinching up the dorsal skin and musculature, the scissors is opened and closed several times as it is advanced towards the radix (Figure 11 29). By utilizing the contralateral hand to pull up the nasal superficial musculoaponeurot

Nasal and Septal Deformities 283 ic system (SMAS), and by digging the blunt scissors into the nasal bones and overlying periosteum, the correct plane is entered. The maneuver is then repeated on the opposite side. The Metzenbaum scissors is next used to connect the intercartilaginous incisions to the transfixion incision. By carefully dividing the intervening fibers, the surgeon should now be able to pass the scissors along the dorsum, over the anterior septal angle, and down the caudal aspect of the septum without impedance. Figure 11 27 A transfixion incision is made between the medial crura of lower lateral cartilages and the caudal edge of septum. Figure 11 28 An intercartilaginous incision is made between the caudal margin of the upper lateral cartilage and the cephalic border of the lateral crus of the lower lateral cartilage. Figure 11 29 Skeletonizing the dorsum is facilitated by pinching up the nasal skin and SMAS with the contralateral hand.

284 Surgical Atlas of Pediatric Otolaryngology Correction of dorsal and bony deformities An Aufricht retractor is inserted between the nasal bone and cartilage, below, and the skin and muscle, above. The dorsal septum is immediately visible from the anterior septal angle back to the rhinion. If a cartilaginous dorsal hump exists, it can now be trimmed with a No 11 or No 15 blade (Figure 11 30). The trimming should be incremental, constantly monitoring the profile after each sliver of cartilage is removed; it is easier to prevent an over-resected dorsum than to correct one. Bony humps or spicules can be addressed by inserting a fine diamond rasp over the bony dorsum, and by rasping with a to-and-fro motion (Figure 11 31). This should be performed equally from each side so as not to create asymmetry. When withdrawing the rasp out of the dorsal pocket, first lift the rasp off the nasal bones so as not to catch and avulse the adjoining upper lateral cartilages. The rasp should be rinsed frequently with saline to remove bone dust and other debris. After checking to make sure that the profile is properly aligned (small modifications can, and often should, be left until after the tip work is completed), bilateral pyriform incisions are made with the electrocautery just lateral to the anterior end of the inferior turbinates. If a sizeable bony hump has been removed, medial osteotomies are seldom necessary. If indicated, however, they are performed by inserting a curved guarded osteotome up through the nasal mucosa at the junction of the upper lateral cartilages and nasal bones on either side of the bony nasal septum. A short oblique osteotomy is created by having the surgical assistant tap the osteotome with a mallet, while directing the osteotome in the direction of the medial canthus (Figure 11 32). Curved guarded osteotomes are then inserted through the pyriform incisions and locked into place on the pyriform rim; proper placement is confirmed by the ability to rock the head back and forth with the handle of the osteotome. A high-low-high lateral osteotomy is performed: (1) high up on the pyriform rim, then (2) low down into the nasomaxillary groove, then (3) high up towards the radix at the level of the medial canthus. By continually palpating the blunt guard of the osteotome under the skin, the path of the osteotomy can be precisely controlled (see Figure 11 32). The nasal bones are gently infractured with manual digital pressure. By keeping the majority of the periosteum over the nasal bones intact, there is much less chance of nasal bone collapse following osteotomy. In performing osteotomies earlier, rather than later, in the rhinoplasty, there is generally less bleeding encountered.

Nasal and Septal Deformities 285 Figure 11 30 The cartilaginous hump is reduced incrementally with a No 11 scalpel blade. Figure 11 31 The bony hump is reduced with a fine rasp. Figure 11 32 Path of medial (dotted line) and lateral (dashed line) osteotomies.

286 Surgical Atlas of Pediatric Otolaryngology Correction of nasal tip deformity The nasal tip is now addressed and three situations exist that are amenable to simple endonasal tip plasty: 1. If the tip shape is acceptable, but its position in space is deemed undesirable, modifications of the underlying septum (caudally or dorsally) may alter rotation or projection. Reduction of the dorsal portion of the caudal septum or the nasal spine area will result in tip deprojection. A triangle of septal cartilage may be trimmed from the most caudal part of the septum (via the transfixion incision) to allow the nasal tip to slightly rotate up. 2. If the tip is slightly bulbous, but the domes of the lower lateral cartilages are close together, a retrograde cephalic trim may be performed via the intercartilaginous incision with aid of an assistant: A fine blunt scissors is used to dissect on both sides of the lateral crus of the lower lateral cartilage (Figure 11 33A). The cartilage is thereby freed from the overlying nasal skin and the underlying vestibular lining. With an assistant helping to evert the lateral crus, a conservative strip from the cephalic margin can be directly excised (Figure 11 33B). This should be performed evenly on both sides, generally removing only 3-4 mm of cartilage. 3. If the tip is bulbous and the domes are far apart or asymmetric, the lower lateral cartilages should be delivered prior to modification: Bilateral infracartilaginous (marginal) incisions are performed with a No 15 blade (Figure 11 34). A blunt fine scissors is used to dissect directly over the top of the lateral crus and exits at the intercartilaginous incision.

Nasal and Septal Deformities 287 A B Figure 11 33 A, A fine scissors is used to dissect superficial and deep to the inv erted cephalic edge of the lateral crus of the lower lateral cartilage. B, Conservative retrograde cephalic trim may now be per formed with a No 15 scalpel blade. Figure 11 34 An infracartilaginous (marginal) incision is made with a No 15 scalpel blade and a sharp double hook at the caudal margin of the lower lateral cartilage.

288 Surgical Atlas of Pediatric Otolaryngology Figure 11 35 The lower lateral cartilage is delivered as a bipedicled chondrocutaneous flap. The resulting bipedicled flap of lower lateral cartilage and vestibular skin is delivered through the marginal incision in anatomic configuration (Figure 11 35). The cephalic margin of the lateral crus is trimmed under direct vision, making sure to leave at least 6-7 mm of intact lateral crura (Figure 11 36). The domes are bound together with 5-0 Prolene suture, thereby narrowing the nasal tip and creating a small degree of projection and rotation (Figure 11 37): . One of the domes is passed under the nasal tip skin and out through the contralateral marginal incision. . Once both domes are delivered to one side, a free 25-gauge needle is used to skewer them and hold them symmetrically. The suture may now be passed in a mattress fashion to unite the domes. . The 25-gauge needle is removed and the newly created tip is returned to its anatomic position beneath the skin and checked for symmetry.

Nasal and Septal Deformities 289 Figure 11 36 Conservative resection of the cephalic portion of the lateral crus of the lower lateral cartilage is performed preserving at least 6 mm of intact lateral crus. Figure 11 37 A horizontal mattress suture of 5-0 clear Prolene is used to narrow the interdomal distance.

290 Surgical Atlas of Pediatric Otolaryngology Incision closure Figure 11 38 Correct position of dorsal onlay graft. A dorsal augmentation graft (Figure 11 38), if indicated, is placed prior to incision closure by tenting up the dorsal skin with the Aufricht retractor and inserting the graft with a bayonet forceps. Fixation can be performed percutaneously with a suture passed through the dorsal skin, the graft, back through the skin, and then tied over a Telfa bolster. Alternately, the caudal end of the implant can be sutured to the dorsal septum with an absorbable suture. The marginal and transfixion incisions are closed with chromic suture, and if a septoplasty was performed, a quilting suture is placed. Two folded Telfa packs are coated with antibiotic ointment and inserted into each nasal passage with a bayonet forceps (Figure 11 39). Paper tape is cut to size and placed over the entire nasal dorsum, with an additional piece wrapped around the nasal tip for support in the early postoperative period. A splint made from Aquaplast is trimmed to size, dipped in hot water, and applied to the nose for 2 minutes (Figure 11 40).

Nasal and Septal Deformities 291 Figure 11 39 Folded Telfa nasal packs are inserted bilaterally. Figure 11 40 Nasal splint. No 2. External approach for rhinoplasty Surgical exposure Well wrung-out cotton pledgets sprayed with oxymetazoline are inserted into the nose with bayonet forceps. If the septum is also going to be addressed, it is infiltrated with local anesthesia. Further injections of local anesthesia are made at the planned incision sites and along the nasomaxillary groove and nasal dorsum. An inverted V incision is marked at the waist of the columella and infiltrated with local anesthesia using a 30-gauge needle.

292 Surgical Atlas of Pediatric Otolaryngology Figure 11 41 Bilateral infracartilaginous incisions (1) are made with the No 15 blade. A fine scissors (2) is used to connect the medial portions of both infracartilaginous incisions in the precrural plane. The transcolumellar incision (3) is then completed with a No 11 blade. Marginal incisions are made at the caudal margin of the lower lateral cartilages as in the endonasal delivery technique. 1. A fine-tipped delicate scissors is inserted in front of the medial crura, from one marginal incision site to the other (Figure 11 41). 2. The scissors is spread vertically to separate the columellar skin from the perichondrium in the precrural space. 3. Following this important maneuver, the point of a No 11 blade is used to complete the inverted V incision, taking care not to lacerate the underlying medial crura. The paired columella arteries are coagulated with a fine tip cautery and the subperichondrial plane is entered with fine scissors. By remaining in this plane, a bloodless dissection can be achieved as the nasal tip cartilages are skeletonized. Dissection proceeds medially up over the domes towards the anterior septal angle (Figure 11 42) and laterally up over the lateral crura (Figure 11 43). From this point on, the dorsal dissection is identical to that for the endonasal approach (see Figures 11 29 to 11 32). The sub-SMAS plane is entered at the anterior septal angle, and with the contralateral hand pinching up the nasal skin and musculature, a Metzenbaum scissors is spread several times while advancing towards the nasion. Septoplasty, if indicated, is performed now. The septum can be easily accessed by dividing the medial crura, entering the membranous columella, and palpating the caudal edge of the quadrangular plate. The technique for this procedure is covered in detail in the preceding section, Septoplasty.

Nasal and Septal Deformities 293 Figure 11 42 A fine scissors is used to dissect over the medial crura and domes in the subperichondrial plane. Figure 11 43 The dissection continues laterally over the lateral crus in the subperichondrial plane. Correction of dorsal and bony deformities Dorsal reduction and osteotomies are performed as described in the preceding section, Endonasal approach for rhinoplasty. Correction of nasal tip deformity Tip modifications may now be made and generally proceed from the bottom up , ensuring a well-supported nasal tip.

294 Surgical Atlas of Pediatric Otolaryngology Figure 11 44 A cartilaginous strut is sutured between the medial crura. A bulbous tip or excess lateral crura, if present, are corrected with a cephalic trim as described in the preceding section, Endonasal approach for rhinoplasty. Next, a straight rigid piece of septal cartilage (previously harvested during septoplasty or for grafting purposes) is inserted between the medial crura (Figure 11 44). The domes are aligned in exact symmetric apposition, and held by passing a 4-0 Polydioxanone (PDS) suture through the crura and columellar strut in a mattress fashion (the knot is buried). The strut is utilized in almost every external rhinoplasty to prevent buckling of the medial crura, provide added tip support, and to set the stage for further tip modification. The next four tip maneuvers may be used alone or in combination and allow the surgeon to tailor the repair to the exact tip pathology encountered. All of these maneuvers are reversible, nondestructive, and rely solely on cartilage suture techniques. 1. A dome-spanning suture (Figure 11 45) is placed if the domes are too far apart or if a small amount of projection is needed. A 5-0 Prolene suture is placed between the two domes in a symmetric fashion and slowly tightened until the desired width between the domes is achieved. The net result of this popular maneuver is to narrow the nasal tip and project and rotate it slightly. 2. A lateral crural spanning suture (Figure 11 46) is used if the supratip area is still too full following conservative cephalic trim. This suture of 5-0 Prolene is placed in a mattress fashion behind the domes, but should not be overly tightened to prevent postoperative airway obstruction caused by internal nasal valve compromise.

Nasal and Septal Deformities 295 Figure 11 45 The interdomal distance is narrowed with a 5-0 clear Prolene horizontal mattress suture. Figure 11 46 The supratip area is narrowed with a 5-0 clear Prolene horizontal mattress suture. Note the placement of the suture behind the domes.

296 Surgical Atlas of Pediatric Otolaryngology Figure 11 47 A recession projection control suture is placed between the caudal edge of the septum and posterior edges of the medial crura. 3. The tip complex may now be set to the proper height with several millimeters of projection or deprojection achievable utilizing the recession projection control suture (Figure 11 47). Both medial crura are grasped with a forceps and positioned at the desired height along the caudal septum. Next, a 4-0 PDS suture is placed from the midway point on the caudal margin of the septum to the posterior edges of the medial crura. By tying this suture tightly, the tip complex is now fixed at the appropriate level of projection or recession. 4. Finally, if further tip rotation is desired, a tip rotation suture (Figure 11 48) may be utilized. This suture of 4-0 PDS is placed from just behind the anterior septal angle on the dorsum of the septum to the posterior edges of the superior aspect of the medial crura. As the suture is slowly tightened, the tip complex will be rotated around the anterior septal angle. When the desired degree of tip rotation is achieved, the knot is secured. Incision closure A dorsal augmentation graft (see Figure 11 38), if indicated, is placed prior to incision closure by tenting up the dorsal skin with the Aufricht retractor and inserting the graft with a bayonet forceps. Fixation can be performed percutaneously with a suture passed through the dorsal skin, the graft, back through the skin, and then tied over a Telfa bolster, or alternately, by suturing the caudal end of the implant to the dorsal septum with an absorbable suture. The marginal and transcolumellar incisions are closed with chromic and proline suture, respectively (Figure 11 49); if a septoplasty was performed, a quilting suture is placed.

Nasal and Septal Deformities 297 Figure 11 48 A rotation control suture is placed between the dorsal edge of the anterior septum (anterior septal angle) and the superior posterior edges of the medial crura. Figure 11 49 The transcolumellar incision is meticulously closed using a 6-0 Prolene suture on a fine needle.

298 Surgical Atlas of Pediatric Otolaryngology Two folded Telfa packs are coated with antibiotic ointment and inserted into each nasal passage with a bayonet forceps (see Figure 11 39). Paper tape is cut to size and placed over the entire nasal dorsum; additional tape should not be placed around the nasal tip as this may compromise blood supply. A splint made from Aquaplast is trimmed to size, dipped in hot water, and applied to the nose for 2 minutes. Postoperative Care Nasal packing is removed on the first postoperative day. Ice packs over the eyes are recommended for the first 48 hours. The nasal splint can be removed on day 7 (along with sutures if the external approach has been employed). Gentle nasal exercises are begun in order to maintain bony alignment, by having the patient (or a parent) gently squeeze the nasal bones together a few times a day for the first 7 days after splint removal. Pressure should be light and the patient should not experience pain during this maneuver. At 2 weeks, the patient may resume light aerobic activity; at 4 weeks, running and jumping are allowed; and at 6 weeks, full activity may be resumed. Complications Complications following rhinoplasty are rare, but include excessive bleeding, septal hematoma, nasal valve compromise, and over- or undercorrection of deformities. Many such deformities are minor and can be corrected with a small revision procedure after an appropriate healing time (usually a minimum of one year following primary rhinoplasty). BIBLIOGRAPHY Crysdale WS, Djupesland P. Nasal obstruction in children and infants: evaluation and management. In: Myers EN, editor. Advances in otolarygology. Volume XIII. CV Mosby; 1999. Crysdale WS. Clinical challenges in otolaryngology (commentary): septoplasty in children yes, but do the right thing. Arch Otolaryngol Head Neck Surg 1999;125:701. Crysdale WS. External septoplasty in children. J Otolaryngol 1996;25:257 60. Tardy ME. Rhinoplasty; the art and science. Philadelphia: WB Saunders; 1997. Tebbetts JB. Primary rhinoplasty: A New Approach to the Logic and Techniques. CV Mosby (St. Louis, MO); 1998. Toriumi DM. Open structure rhinoplasty: featured technical points and long-term follow-up. Facial

Plastic Clin N Am 1993;1:1 22. Walker P, Crysdale WS. External septorhinoplasty in children patient selection and surgical technique. J Otolaryngol 1994; 23:28 31. Walker P, Farkas L, Crysdale WS. External septoplasty in children: outcome and e ffects on growth. Arch Otolaryngol Head Neck Surg 1993;119:984 9.