Historical overview: animal studies

Pediatric septoplasty became the focus of multiple animal studies over the next 20 years, a few of which are landmark studies worth recognizing because they are often referred to when discussing this subject. Their results varied, and depending on which model was used, either confirmed the fears of clinicians or showed no effect on midface growth.

Sarnat and Wexler showed that moderate-size perforations in the nasal septum of young rabbits led not only to the expected saddling of the nasal dorsum, but also to significant underdevelopment of the maxilla, with resultant class III occlusion. This deformity was not noticed when the same procedure was performed in adult rabbits. Hartshorn repeated the procedure performed by Sarnat and Wexler on canine pups and noted a similar dramatic retardation of midface growth.

Stenstrom and Thilander followed these studies by looking at the effect of septal-defect size on young guinea pigs. They found that the nasal septal cartilage was not a primary growth center in these animals, because only defects that included the bony septum resulted in skeletal deformity. Fuchs’ studies on the mucoperichondrium in young rabbits revealed its importance in the survival of underlying septal cartilage and its contribution to skeletal growth and deformation if it alone is resected. Realizing the crucial role of the mucoperichondrium, Bernstein showed that preserving septal mucoperichondrial flaps in young pups did not result in any perceptible growth disturbances, whether cartilaginous septum was removed or autotransplanted. Interestingly, in septums from which cartilage was removed, there was evidence of cartilage regrowth at 10 months, and in septums from which cartilage was removed and autotransplanted, the cartilage remained viable.

Historical overview: human studies

With the later animal studies showing that a growing nasal septum could be altered without affecting long-term growth, longitudinal studies on children began appearing, with encouraging results. Most of the studies were on children with a strong indication to undergo septal manipulation at a young age. McComb began performing primary rhinoplasty when repairing cleft lip nasal deformities in young children in the 1970s and noted no long-term growth effects. He performed an 18-year longitudinal study of nasal and midface growth and found no significant difference when subjects who had surgery were compared with age-matched normal subjects and age-matched control subjects with cleft lips who did not have rhinoplasty.

Clinical studies became more common in the 1980s and 1990s, but the numbers were small and the statistical power inherently weak. More recently, surgeons in Toronto, Canada, began using anthropometric measurements to follow children undergoing septoplasty. A recent study by El-Hakim and colleagues followed the anthropometric measurements of children who underwent septoplasty via an external approach with autotransplantation of the quadrilateral cartilage and compared their craniofacial development to that of age-matched control subjects. There were no deleterious effects on the development of the nose or midface. However, there was a statistically significant trend in the shortening of the nasal dorsum and nasal tip protrusion, leaving the reader with a slight hesitation to call open season on the pediatric septum.

There remains a lack of a clear consensus in the literature regarding the developmental effects of septoplasty in children. However, the more recent literature mentioned above shows that septoplasty can be performed safely in a selected population using mucoperichondrium- and cartilage-preserving techniques. Even with these techniques, the authors believe the indications for septoplasty in children therefore fall into a carefully selected patient population with an assured diagnosis. When done with the proper technique, the surgery can be effectively used to correct traumatic deformities, nasal airway obstruction, dermoids, septal abscesses, septal hematomas, and sleep apnea.

Historical overview: human studies

With the later animal studies showing that a growing nasal septum could be altered without affecting long-term growth, longitudinal studies on children began appearing, with encouraging results. Most of the studies were on children with a strong indication to undergo septal manipulation at a young age. McComb began performing primary rhinoplasty when repairing cleft lip nasal deformities in young children in the 1970s and noted no long-term growth effects. He performed an 18-year longitudinal study of nasal and midface growth and found no significant difference when subjects who had surgery were compared with age-matched normal subjects and age-matched control subjects with cleft lips who did not have rhinoplasty.

Clinical studies became more common in the 1980s and 1990s, but the numbers were small and the statistical power inherently weak. More recently, surgeons in Toronto, Canada, began using anthropometric measurements to follow children undergoing septoplasty. A recent study by El-Hakim and colleagues followed the anthropometric measurements of children who underwent septoplasty via an external approach with autotransplantation of the quadrilateral cartilage and compared their craniofacial development to that of age-matched control subjects. There were no deleterious effects on the development of the nose or midface. However, there was a statistically significant trend in the shortening of the nasal dorsum and nasal tip protrusion, leaving the reader with a slight hesitation to call open season on the pediatric septum.

There remains a lack of a clear consensus in the literature regarding the developmental effects of septoplasty in children. However, the more recent literature mentioned above shows that septoplasty can be performed safely in a selected population using mucoperichondrium- and cartilage-preserving techniques. Even with these techniques, the authors believe the indications for septoplasty in children therefore fall into a carefully selected patient population with an assured diagnosis. When done with the proper technique, the surgery can be effectively used to correct traumatic deformities, nasal airway obstruction, dermoids, septal abscesses, septal hematomas, and sleep apnea.

Prevalence

In contrast to the adult population, septoplasty is not a commonly performed operation in children, with most series averaging 20 patients. In the authors’ experience, one of the more common indications for pediatric septoplasty is severe nasal obstruction because from 7% to 12% of children snore, but less than 1% of young children have clinical obstructive sleep apnea syndrome. Even then, the majority of cases are not due to septal deviation. Thus, it is important to remember that making the correct diagnosis is paramount.

Evaluation of the patient

The child with chronic nasal obstruction is a common referral for the otolaryngologist, and it is the exception when the cause is limited to the nasal septum. Proper evaluation of the patient and treatment of any other properly identified causes will often negate the need for septoplasty, even in patients with a tortuous septum. The clinician must always keep in mind the factors noted in Box 1 .

Fiberoptic endoscopy is the most effective method of initial evaluation and will reveal most of the factors noted in Box 1 . Although it is not a universal practice, the authors believe that nasal endoscopy is often indicated in the evaluation of the child with nasal obstruction and should be performed before considering septoplasty. If the diagnosis remains in question, a CT scan can be helpful, especially if there is concern for a congenital nasal mass. Only after all other causes have been ruled out or treated should one consider a septoplasty for nasal obstruction. Even then, unless the obstruction is secondary to severe septal deformity, the authors prefer to wait until the child is 5 or more years old.