Septoplasty in children: Results of 250 cases

Backround: Septoplasty in children is still a matter of debate, because it is thought that a surgical procedure on a developing structure might produce some adverse effects on normal nasal and facial growth.On the other hand septal deviation in children may alter the early physiological process of breathing, causing obligatory mouth breathing and consequently changing craniofacial development and even intellect. Objectives: The goal of this retrospective study is to indicate the importance of septoplasty in children,to evaluate the effects of paediatric nasal septal surgery on normal nasal and facial growth, improvement of symptoms and any complications of surgery. Methods: This is a retrospective study of 250 children in the age group of 7-14 years done at Maleka nursing Home , Bogra, Human care hospital, Rajshahi and Khidma hospital Dhaka,from January 1999 to December 2014.All patients were selected from history, clinical examination and selected investigations. All patients had X-ray soft tissue nasopharynx done to see adenoid enlargement.Some patients had done PTA and tympanometry to confirm OME. All patients had septoplasty done with left hemitranfixional incision with elevation of left mucoperichondrial flap and elevation of both mucoperiosteal flaps. In addition adenoidectomy was done for adenoid enlargement and myringotomy with grommet insertion for OME. Patients were followed up on day 8, day 15, 1 mothh, 6 month and one year after operation. Results: Out of 250 children there were 163 male(65.2%)and 87 female(34.8%).Age ranged from 7 to 14 years,lowest number of patients were between 7 and 8 years old-64(25.6%),between 9 and 11 years-73(29.2) and 113(45.2%) between 12 and 14 years.210 patients had septal deviation to left side(84%) Patient felt improvement in nose breathing in 85% of cases.The most often complication was nasal blockage due to insufficient removal of deviated septum in 9.2 % of cases.We had synechia in 8 cases and septal haematoma in 2 cases.There were no asthetic deformities. Conclusion: Effective septal correction by septoplasty in children not only relieves nasal blockage but also controls the associated symptoms.Septolasty in early childhood does not produce any untoward events in terms of the growth and development of the nose and face.


Introduction
Nasal septal deviation produces nasal obstruction, nasal congestion, crusting, epistaxis, eustachian tube dysfunction leading to secretory otitis media, acute and chronic suppurative otitis media.So effective septal correction by septoplasty not only alleviates the nasal obstruction but also controls the associates symptoms. 1eptoplasty in adults is a well -established surgery but in children is still a matter of open discussion, because it is thought that a surgical procedure on a developing structure might produce some adverse effects on normal nasal growth. 2,3.Other group indicate surgery based on the explanation that the sooner septal deviation of a child is corrected , the greater chance of developing normal breath and therefore a suitable facial growth. 4,5.Of the 31 children of 6-14years age, undergoing submucous resection of the septum,32% resulted in some nasal dorsum effects, (Hayton,1948).Since then SMR was not recommended in children. 1

Methods
This retrospective study had 250 patients, in the period from January 1999 to December 2014 done at Maleka Nursing Home, Bogra, Human care hospital, Rajshahi and Khidma Hospital, Dhaka.All patients had X-ray soft tissue nasopharynx done to see adenoid enlargement and some selected patients had PTA and Impedance done.Patients underwent septoplasty and associated procedures such as partial inferior turbinectomy, electrocautery, adenoidectomy, myringotomy and insertion of grommets, when indicated in the same surgery under general anaesthesia.Initially a sterile cotton ballsoaked in adrenalin concentration of 1:2000 is placed in both nostrils for 20 minutes before surgery.A septal incision is given on the left side along the caudal border of the nasal septum.Left mucoperichondrial and mucoperiosteal flap and right mucoperiosteal flaps are elevated.Cartilagenous and bony deviations are excised conservatively to preserve the growth of septal cartilage, therefore avoiding abnormalities in nasal growth.After repositioning of flaps incision line is closed with quilting sutures and nasal splints used with nasal packs kept for 48 hours and splints for 7 days.Patients were followed up on day 8 for removal of splints, day 15 to remove any crusts to prevent synechia, one month, six months and one year interval.

Discussion
There is controversy in the literature about the consequences of septoplasty for septal deviation in children, and some studies have shown that when done early the procedure brought benefits in the short and long term. 5ispenza et al stated that more important than the age of indication for the procedure is the degree of nasal obstruction, placing it as an absolute indication, because nasal obstruction during infancy disrupts the normal development of the angle of the skull base and consequently the maxillofacial growth and may cause malocclusion and jaw protrusion with bone deformities, confirmed even with anthropometric measurements. 6Others also claimed that delay defect correction can bring negative effect on organ systems that play a role in somatic and psychic development of the child including voice changes and sleep disturbances, but speculated that in some situations monitoring should be done for real indication for surgical treatment. 7,8,9,10A study done by Ortaz & Olmedo of 44 patients aged between 8 and 12 years old who underwent septal surgery showed efficacy in relation to nasal obstruction and demonstrated that surgery when performed conservatively does not harm the facial growth or promote nasal deformities. 11In this study out of 250 patients none had any nasal or facial deformity at short and long term follow-up although 9.2% had recurrence of septal deviation due to conservative approach.

Conclusion
Septoplasty in childhood does not produce any untoward events in terms of the growth and development of the nose and face.
Although deviation of the septum has a tendency to recur after surgery, results is fairly satisfactory in children.

Table - II
Age of children having septoplasty(n=250)

Table - IV
List of surgical procedures(n=250)

Table - V
Complications of septoplasty(n=250) deviation Fig-1: Septal deviation to the left