Evolution of Correction of the Deviated Nasal Septum

[Downloaded free from http://www.amhsjournal.org on Thursday, December 27, 2018, IP: 185.12.69.148]

Medical History

Evolution of Correction of the Deviated Nasal Septum – A Historical Overview Vijayalakshmi Subramaniam, Mubeena Basheer, Subhodha Hosagadde R Department of Otorhinolaryngology, Yenepoya Medical College, Mangalore, Karnataka, India

Abstract Septoplasty is one of the most frequently performed surgeries by otolaryngolopgists. Surgical techniques for correction of the deviated nasal septum have evolved over the years to ensure better outcomes for patients. This article delves into the developments in techniques for correction of deviated nasal septum over time. Keywords: Caudal deviation, deviated nasal septum, septoplasty, submucous resection

History is not a burden on the memory but an illumination of the soul. ‑Lord Acton

Ancient Period

Introduction Delving into the historical developments of any surgical procedure and the experiences of great surgeons helps us discern the value of what has been done previously. It is also thought‑provoking and drives ingenuity, thus facilitating further advancement. Nasal obstruction caused due to deviated nasal septum is one of the most common problems encountered by the otolaryngologist. With better understanding of nasal anatomy and physiology, techniques of correction of the deviated nasal septum have evolved and refined to ensure better functional outcomes for patients. Septoplasty is one of the most frequently performed surgeries by otolaryngologists. It is more often performed for functional rather than aesthetic indications. The success rate of septoplasty in achieving at least 50% reduction in nasal symptoms is reported to be 71%. [1‑6] Conventionally, functional septoplasty was performed by otolaryngologists, while cosmetic rhinoplasty was performed by plastic surgeons. Ever since the role of the nasal pyramid in the causation of nasal obstruction has been recognized, septorhinoplasty is being performed for both functional and cosmetic purposes. In this article, an attempt has been made Access this article online Quick Response Code:

to review the developments in techniques of septal surgery over time.

Website: www.amhsjournal.org

DOI: 10.4103/amhs.amhs_129_18

Surgery for nasal trauma has been described as early as the Babylonian Hammurabi legal code, Egyptian Edwin Smith Surgical Papyrus and the Roman text of Celsus.[7] The Egyptian Edwin Smith Surgical Papyrus [Figure 1] which gives the first account of treatment of nasal injuries dates back to 3000 BC. Nasal fractures are described to have been treated by nasal manipulation, followed by plugging nostrils using lint, swabs and linen as absorbents. External splints of thin wood padded with linen were applied. Grease and honey were smeared on fresh wounds.[8] Although Egyptian physicians have been reported to have used instruments to remove the brain through the nose as part of the mummification process, the earliest report of a nasal examination is attributed to Sushruta [Figure 2], an Indian Ayurvedic physician who wrote the Sushruta Samhita in 600 BC. He designed the Netiyantra – a tubular nasal speculum made of bamboo and used it for nasal examination, Address for correspondence: Dr. Vijayalakshmi Subramaniam, Department of Otorhinolaryngology, Yenepoya Medical College, Mangalore ‑ 575 018, Karnataka, India. E‑mail: [email protected] This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: [email protected]

How to cite this article: Subramaniam V, Basheer M, Hosagadde RS. Evolution of correction of the deviated nasal septum – A historical overview. Arch Med Health Sci 2018;6:293-7.

© 2018 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow

293

[Downloaded free from http://www.amhsjournal.org on Thursday, December 27, 2018, IP: 185.12.69.148] Subramaniam, et al.: Evolution of septal surgery

Figure 1: World’s oldest surviving surgical document (Source: http:// historicalhoney.com/cosmetic‑history/)

Figure 2: Sushruta – Indian Ayurvedic Physician (Source: http://www. iaimhealthcare.org/acharya‑sushruta‑father‑of‑surgery/)

surgeries to remove nasal polyps and tonsillectomies. Around the 5th century BC, Hippocrates classified nasal injuries from simple bruises to complicated fractures and suggested detailed treatment for each case, which included the use of bandages and braces made from branches of the olive tree and reconstruction of the nasal bone and cartilage.[9,10] Later, the removal of septal spurs and full‑thickness resection of deviated portions of the septum was initiated, but was discontinued due to the problem of septal perforations.[11]

method for improved surgical outcomes in 1899. During the same time, Asch advocated the transection of septum using scissors with fracturing of septum using digital manipulation to disrupt cartilage memory, thereby preventing recurrence of deviation.[11,13,14]

There came a stalemate to further developments in the treatment of deviated nasal septum until the 18th century.

From Renaissance to the Nineteenth Century The correction of deviated nasal septum using daily digital pressure was proposed by Quelmaltz in 1757.[12] Adams promoted forcible dilatation of nose to create a septal fracture and then splinting it. He recommended a steel screw compressor to be worn by the patient continuously for 2–3 days after procedure to keep the septum in the midline. After the removal of compressor, he advised the use of ivory plugs to support the septum to promote healing in the midline. Spurs were addressed by shaving down of convexities by Langenbeck (1843), Dieffenbach (1845) and Chassaignac (1851), while a punch forceps was employed for complete removal of deviations by Rubrecht (1868). Ephraim Fletcher Ingals [Figure 3] who is also known as the father of modern septoplasty removed deviated portions of septal cartilage en bloc with preservation of mucosal flaps bilaterally in 1882. This technique was called “window resection.” Complete resection of the cartilaginous septum along with the mucous membrane on one side allowing the defect to heal by granulations was described by Kreig in 1886. The Bosworth procedure which involved the removal of deviated portion of septum/spurs with mucosa on ipsilateral side and preserving contralateral mucosa soon came into vogue. Boenninghaus began to resect vomer and perpendicular plate of ethmoid in addition to cartilage and recommended this 294

The Twentieth Century The commencement of the 20th century heralded the beginning of the present‑day submucous resection (SMR) of the nasal septum. Gustav Killian of Germany [Figure 4] and Otto Tiger Freer of USA [Figures 5 and 6] recognized the importance of mucosa preservation and preservation of the L‑shaped dorsal and caudal strut to support the nose. Killian employed an oblique incision 0.5 cm posterior to the anterior edge of the septum inferiorly to 1 cm posterior to the anterior edge of the septum superiorly. Subperichondrial flaps were elevated on both sides. The quadrangular cartilage was then freed from the perpendicular plate of ethmoid and removed. After this, the anterior end of the vomer was chiselled out and any remaining obstructing bone was resected. Killian stressed on cutting completely through the perichondrium and elevation of mucoperichondrial flaps away from the septum and leaving mucosa intact to avoid perforation. Freer laid emphasis on the preservation of an L‑shaped dorsal and caudal strut of 6–8 mm to provide support to the nose. While retaining the caudal strut prevented columellar retraction, the dorsal strut retention prevented supratip depression.[11,13‑16] The skull base began to be approached transseptally as early as 1909 for the removal of pituitary tumors by Hirsch. Halsteadt introduced the gingivolabial incision to approach the skull base. Very soon, Cushing performed SMR using a sublabial incision to gain access to the pituitary via the sphenoid sinus.[17,18] Metzenbaum and Peer were the foremost to address the caudal septal deviations using different techniques. Metzenbaum advocated the use of the “swinging door” technique in 1929,

Archives of Medicine and Health Sciences ¦ Volume 6 ¦ Issue 2 ¦ July-December 2018


Figure 3: Ephraim Fletcher Ingals – Father of Modern Septoplasty (Source: http://photoarchive.lib.uchicago.edu/db.xqy?show=browse8.xml | 346)

Figure 5: Otto Tiger Freer (Source: Chittiboina P, Connor DE Jr., Nanda A. Dr. Otto "Tiger" Freer: inventor and innovator. Neurosurg Focus 2012;33:E12.)

which involved repositioning of the caudal end of the septum in the midline. He elevated the mucoperichondrium on one side of the caudal strut and relocated the caudal strut into the maxillary crest. He used sutures to ensure fixation. The traction caused by the mucoperichondrium on the opposite side resulted in recurrence of deflections. He recommended early repair of traumatic caudal septal dislocations even in children as he believed that septum like any other bone or cartilage should be reset immediately to allow for growth of surrounding structures. Complete removal of the caudally deviated cartilage and reinsertion of the cartilage as a free graft wherever possible was introduced by Peer in 1937 to overcome the problem of recurrence. In cases where the removed tissue was unsuitable or insufficient for reinsertion, Peer took a similar sized graft by removing a piece of central portion or more posterior part of quadrilateral cartilage. The removal of entire nasal cartilage and replacing the anterior septum with a single free autograft cut from the excised cartilage was propagated by Galloway

Figure 4: Gustav Killian (Source: Prowse SJ, Makura Z. Gustav Killian: Beyond his dehiscence. J Laryngol Otol 2012;126:1164-8.)

Figure 6: Maurice H Cottle – The architect of the maxilla‑premaxilla approach (Source: https://www.american‑rhinologic.org/history)

in 1946. He recommended placement of graft taken from the septal cartilage with traction sutures and removal of these traction sutures after the graft was secured in place with mattress sutures. A modification of the swinging door technique was attempted by Noorman where the dislocated septum was shifted to the opposite side of dislocation to take advantage of the maxillary crest which acted as a door stop. Goldman described scoring, resection and suturing of the dislocated caudal septum. Later, Lawson described a modification of the Goldman technique which involved resection of a triangular piece of the caudally deviated cartilage and suturing the septum to the maxillary spine to avoid columellar retraction.[19‑22] Although SMR operation began to be widely adopted for septal correction worldwide, some of the related problems also became evident. It was recognized that supratip depression and columellar retraction occurred when SMR was used for deviations anterior to an imaginary line drawn from the frontonasal spine to the anterior maxillary spine. Even retaining the caudal and dorsal strut was not 100% successful in


295


preventing these problems. Surgeons tried many modifications based on their experience to avoid these problems, but soon realized that deviations recurred because of unequal scar contraction between the two septal flaps.[11,13‑16] Saddling/supratip depression occurred due to the absorption of the autograft. Immobilization of the membranous septum by the lower end of the septum gave the nose a rather unconventional appearance. This steered further thought process which encompassed the nasal pyramid structures. The upper and lower lateral cartilages were recognized as primary supports for the cartilaginous nasal dorsum due to the attachment of the upper lateral cartilage to the nasal bone, frontal process of maxilla, and to the septum by Fomon et al. They alluded that cicatrization of the deskeletonized connective tissue resulted in saddling of the nasal dorsum. Hence, they conceived the technique of complete resection of the nasal septum followed by replacement with strips of cartilage including a columellar batten graft in order to prevent contracture.[21] Cottle (1946) pointed out that dealing with the deviated septum alone would not ensure good functional outcome and emphasized on addressing any portion of the nose obstructing nasal airflow during surgery. Nasal airflow could be hampered by collapse of overly large or dilated nostrils, nostril stenosis from previous surgery or misdirection of air currents by a large nasal dorsal hump. Cottle and Loring contended that the Killian’s incision would not permit satisfactory access to the caudal septal deviation due to its placement being way too posterior and proposed the hemitransfixion incision. They advocated the “maxilla‑premaxilla” approach where lesser amount of septal cartilage was removed to prevent septal perforation and saddling. Caudal dislocations, rotated nasal tips and deformities of the nasal floor could be tackled using this approach. After making the hemitransfixion incision, the septal mucosa is elevated on the ipsilateral side. Dissection is then continued inferiorly toward the nasal spine, and attachments to the maxillary crest and premaxilla are separated to expose the inferior edge of septum and maxillary crest. This exposure permits repositioning of the septum in the midline. Contralateral flap is not elevated entirely. It begins at the caudal end of the septum and only an inferior tunnel of mucosa is elevated to remove the deviated portion of septum. Disruption of blood supply to septum is minimized by not elevating a superior mucosal flap. Springiness of the cartilage could be reduced by various techniques such as wedge resection, scoring, or morselization. Wedge resections are placed on the convex side of the cartilage in the axis of deviation and bolstered with sutures. Scoring the concave side of deviated cartilage weakens cartilage and permits the shorter concave side to unfurl and remains straight. The resected septum could be morselized and replaced to provide support and prevent scarring. The curvature of cartilage during healing could be thwarted by a mattress suture on convex side of the septal deviation. A thin piece of cartilage or ethmoid bone could be used as a batten graft on concave side to provide support for straightening the septum.[23,24] 296

Extracorporeal septoplasty began to be done by King and Ashley in 1952 for markedly deviated septums. Although both open and closed approaches are described, the open approach permits better exposure and was hence preferred. The entire cartilaginous septum is removed in this procedure after bilateral mucoperichondrial flap elevation. The septal cartilage is refashioned into a straighter L‑shaped strut or neoseptum, which is reimplanted. If the neoseptum cannot be created from a single piece of cartilage, many small pieces of cartilage are sutured together.[25]

The Endoscopic Era Over the years, the technique of septoplasty has evolved a great deal with better understanding of the anatomy and physiology of the nasal septum. The turn of the 21st century saw the advent of the endoscope for the correction of deviated nasal septum. Nasal endoscopes were first used for septoplasty by Lanza et al. and Stammberger.[26‑28] Endoscopic techniques allowed better visualization and lighting. Targeted removal of septal spurs can be carried out by making an incision over the apex of the spur and elevating the mucosa over the spur. The flaps are repositioned after removing the spur. Even in patients with septal perforation, septal mucosal incisions can be taken posterior to the perforation and deviations posterior to the perforation could be tackled. Availability of better instruments and the endoscope has added to the ability to correct even complex septal deformities. The superior part of the septum was removed for access to the frontal sinus by Draf in 1991.[29] The nasoseptal mucosal flap of Hadad–Bassagasteguy based on the nasoseptal artery has revolutionized repair of dural defects in patients with cerebrospinal fluid rhinorrhea. This flap is a very reliable resource for defects in the anterior, middle, clival, and parasellar skull base. Because this is done endoscopically, morbidity has been greatly reduced.[30] Surgery for correction of septal deviations has come a long way over the years with availability of many techniques. Septoplasty, however, continues to remain a challenging procedure for the otolaryngologist. No single technique suits all patients. It is essential to assess the location, extent, and severity of septal deviation and choose the appropriate surgical technique that would give best results for the patient. “Since the study of medicine is a lifelong learning process, the study of surgical history can contribute to make this educational effort more pleasurable and provide constant invigoration… There’s really no way to separate one’s own practice from the experiences of all the great surgeons that have gone before” ‑Ira M. Rutkow, 2004

Financial support and sponsorship Nil.



Conflicts of interest

There are no conflicts of interest.

References 1. Thomas A, Alt J, Gale C, Vijayakumar S, Padia R, Peters M, et al. Surgeon and hospital cost variability for septoplasty and inferior turbinate reduction. Int Forum Allergy Rhinol 2016;6:1069‑74. 2. Rotenberg BW, Pang KP. The impact of sinus surgery on sleep outcomes. Int Forum Allergy Rhinol 2015;5:329‑32. 3. LoSavio PS, O’Toole TR. Surgery of the nasal septum and turbinates. In: Batra PS, Han JK, editors. Practical Medical and Surgical Management of Chronic Rhinosinusitis. Cham: Springer; 2015. p. 483‑507. 4. Gillman G. Septoplasty. In: Myers E, Kennedy D, editors. Rhinology. Alphen Aan Den Rijn, Netherlands: Wolters Kluwer; 2016. p. 7‑21. 5. Ketcham AS, Han JK. Complications and management of septoplasty. Otolaryngol Clin North Am 2010;43:897‑904. 6. Siegel NS, Gliklich RE, Taghizadeh F, Chang Y. Outcomes of septoplasty. Otolaryngol Head Neck Surg 2000;122:228‑32. 7. Pellegrini VM. History of rhinologic surgery. Am J Cosmet Surg 1996;13:103‑4. 8. Whitaker IS, Karoo RO, Spyrou G, Fenton OM. The birth of plastic surgery: The story of nasal reconstruction from the Edwin Smith Papyrus to the twenty‑first century. Plast Reconstr Surg 2007;120:327‑36. 9. Lascaratos JG, Segas JV, Trompoukis CC, Assimakopoulos DA. From the roots of rhinology: The reconstruction of nasal injuries by Hippocrates. Ann Otol Rhinol Laryngol 2003;112:159‑62. 10. Stammberger H. History of rhinology: Anatomy of the paranasal sinuses. Rhinology 1989;27:197‑210. 11. Aaronson NL, Vining EM. Correction of the deviated septum: From ancient Egypt to the endoscopic era. Int Forum Allergy Rhinol 2014;4:931‑6. 12. Meloni F, Bozzo C, De Peacock MR. Sub‑mucous resection of the nasal septum. J Laryngol Otol 1981;95:341‑56. 13. Meloni F, Bozzo C, De Filippis C. The evolution of the techniques used to correct nasal septum function. Acta Otorhinolaryngol Ital 1996;16:180‑8. 14. Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: Techniques in septoplasty. Otolaryngol Clin North Am 2009;42:241‑52.

15. Hinderer KH. History of septoplasty. In: Fundamentals of Anatomy and Surgery of the Nose. Birmingham, Alabama: Aesculapius Publishing Co.; 1971. p. 1. 16. Most SP, Rudy SF. Septoplasty: Basic and advanced techniques. Facial Plast Surg Clin North Am 2017;25:161‑9. 17. Henderson WR. The pituitary adenomata. A follow-up study of the surgical results in 338 cases. (Dr. Harvey Cushing’s series). Br J Surg 1939;26:811‑921. 18. Pendleton C, Adams H, Mathioudakis N, Quiñones‑Hinojosa A. Sellar door: Harvey Cushing’s entry into the pituitary gland, the unabridged Johns Hopkins experience 1896‑1912. World Neurosurg 2013;79:394‑403. 19. Pastorek NJ, Becker DG. Treating the caudal septal deflection. Arch Facial Plast Surg 2000;2:217‑20. 20. Lee JW, Baker SR. Correction of caudal septal deviation and deformity using nasal septal bone grafts. JAMA Facial Plast Surg 2013;15:96‑100. 21. Fomon S, Syracuse VR, Bolotow N, Pullen M. Plastic repair of the deflected nasal septum. Arch Otolaryngol 1946;44:141-56 22. Lawson W, Westreich R. Correction of caudal deflections of the nasal septum with a modified Goldman septoplasty technique: How we do it. Ear Nose Throat J 2007;86:617‑20. 23. Cottle MH, Loring RM. Surgery of the nasal septum; new operative procedures and indications. Ann Otol Rhinol Laryngol 1948;57:705‑13. 24. Cottle MH, Loring RM, Fischer GG, Gaynon IE. The maxilla‑premaxilla approach to extensive nasal septum surgery. AMA Arch Otolaryngol 1958;68:301‑13. 25. King ED, Ashley FL. The correction of the internally and externally deviated nose. Plast Reconstr Surg (1946) 1952;10:116‑20. 26. Lanza DC, Kennedy DW, Zinreich SJ. Nasal endoscopy and its surgical application. In: Lee KJ, editor. Essential Otolaryngology: Head and Neck Surgery. 5th ed. New York: Medical Examination; 1991. p. 373‑87. 27. Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia: BC Decker; 1991. p. 432‑3. 28. Gupta N. Endoscopic septoplasty. Indian J Otolaryngol Head Neck Surg 2005;57:240‑3. 29. Draf W. Endonasal micro‑endoscopic frontal sinus surgery: The Fulda concept. Oper Tech Otolaryngol Head Neck Surg 1991;2:234‑40. 30. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: Vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882‑6.


297