6.1 Septal Surgery in Children

Surgery of the pediatric nose presents special difficulties. The goal of nasal surgery in children is to improve function, but in a way that does not compromise further nasal and midfacial development. The ratio of the bony and cartilaginous components of the nasal skeleton changes in growing children, and it is not until adulthood that a large portion of the nasal septum consists of bone. ² The cartilaginous nasal septum is currently viewed as the dominant growth center in the developing midface, interacting with the suture-based growth of the bony skeleton. Loss or lesions of the septodorsal cartilage may lead to growth abnormalities of the nose and maxilla. ³ This means that the earlier surgery is performed on the pediatric septum, the greater the risk of adverse effects on midfacial growth. Injuries to the cranial suture typically lead to saddle nose deformity, while lesions of the inferior suture lead to hypoplasia of the cartilaginous nose with abnormal growth of the premaxilla (Binder syndrome). It is important, therefore, to maintain the integrity of the supportive and growth zones during septoplasty. Particular care should be taken not to separate the cartilaginous septum from the perpendicular plate, as this area is crucial for the support and further growth of the nasal septum and dorsum. ⁴ Very strict criteria should be applied in selecting children for septal surgery, and this determination should always be made by an experienced surgeon. Submucous septal surgery can be performed for the treatment of severe posttraumatic, congenital, and other deformities in selected children. ⁵ Great care should be taken, however, to avoid destabilizing any part of the keystone area and to preserve a broad, sturdy cartilage pillar below the cartilaginous nasal dorsum to prevent postoperative saddle deformity. It is seldom justifiable to accept significant nasal airway obstruction before 16–18 years of age.

On the whole, septal deviations are rare in younger children. They most commonly result from growth-related movements of the mosaic components in the medial nasal wall before and during puberty. Deviations in children usually represent deformities involving the anteroinferior portion of the septum. Any corrective surgery should preserve the integrity of the perichondrium and growth zones, e.g., the caudal septum, premaxilla, and the suture with the perpendicular plate and vomer. The surgery should be atraumatic and chondroplastic. Any cartilage pieces that are removed should be straightened and reimplanted at their original site. Septal cartilage will retain its regenerative capacity even after surgical trauma.

Nasal trauma in children can have various effects, typically producing a greenstick fracture of the nasal pyramid. Septal hematomas or abscesses should be excluded or managed appropriately ( Figs. 6.2, 6.3 ).

Severe or recurrent trauma may lead to abnormal maxillofacial development as in Binder syndrome, requiring later correction by a reconstructive procedure ( Fig. 6.3 ).