Endonasal Tongue in Groove Septoplasty

Table 1: pre-operative and post-operative mean and standard deviation of the NOSE questionnaire.

On following up the patients after 60 days, four patients were found to have posterior septal perforation (all of less than 0.5 cm, not causing any complaints, so none of them was addressed). 14 patients complained of tip stiffness. 9 patients had an infection of the non-absorbable suture, of which we removed the suture for 4 of them as they did not respond to the topical nor the systemic antibiotics.

DISCUSSION

Since the origin of septal surgery, the repair of the caudal end of the septum has been a challenge for the rhinological surgeon. The traditional submucous resection as described by Freer²³ and Killian²⁴ emphasised the importance of removing the deviated septum portion; but to allow an adequate caudal and dorsal cartilage strip to prevent external nasal deformities. The caudal end of the septum is often the reason of the obstruction, Unless removed or straightened, the objective of the surgery will be deposed. The caudal septum and lower lateral cartilage (LLCs) create an important part of the external nasal valve ²⁵. Thus, any deviation at this level will increase airflow resistance and a feeling of a blocked nose, also will cause cosmetic concerns due to the apparent bulge of the caudal septal end into the nostril as well. These deformations may arise from earlier trauma, or may be developmental.²⁶ We operated on 23 revision cases, all did not have the caudal dislocation addressed during the primary septoplasty.

The deviations from the caudal septum can be graded as mild , moderate and severe. There has been no single correction procedure known to be successful in all conditions. Most approaches to the caudal nasal septum can be categorised as either cartilage reshaping or septal reconstruction manoeuvres. Although all techniques could be approached through an endonasal or external approach, the majority of caudal septal reconstruction manoeuvres are easier to access through an external approach¹

The caudal septal deviation can manifest as a form of cephalocaudal or anteroposterior deviation. Cephalocaudal deflections can be repaired using vertical sleeve resection or swinging door technique²⁷ .When the caudal septum is separated from the anterior nasal spine, a proper relationship between the anterior nasal spine and the posterior end of the caudal septum can be restored. In cases of deviation in the anteroposterior direction, the caudal septum represents a C-shaped convexity, or acute angulation, less frequently. The underlying condition of caudal anteroposterior deviation is generally the excess septal cartilage length encased between the maxillary crest and the nasal roof. A small portion of the posterior end of the caudal septum can be resected to straighten the cartilage, which can place the caudal septum in a straight midline position²⁸.

The normal caudal septum has many essential, functional, anatomical relationships. It extends anteriorly from the nasal spine, as the continuation of the main septum. The attachment point establishes the septum posterior angle. As it ascends towards the nasal dorsum, an anterior cartilage projection creates the septum 's intermediate angle. inability to recognise the intermediate angle's aesthetic value, and its excision, results in straight columella – an unwanted iatrogenic problem. The caudal septum and lower lateral cartilages (LLCs) not only form an important component of the external valve but are also responsible for the majority of the nasal tip support²⁵. We did not perform any routine excisions of the caudal septum, we only did scoring to straighten the caudal septum to preserve the tip support and the intermediate angle. And if excisions was required especially in anteroposterior caudal deviation, we only did a controlled excision removing the excess cartilage with preserving the intermediate angle, hence preserving the tip support and the shape of the columella.

Many methods have been used to control the caudal septum. Ellis²⁹ used a suture procedure as an addition to correct deviation of the caudal septum. Kridel et al³⁰ used the technique of tongue-in-groove to correct the excess columellar show and caudal septal deviation. Metzinger et al³¹ used the ethmoid bone sandwich grafting for caudal septal deviation correction via an external rhinoplasty approach. For the correction of dorsal and caudal septal deviations, Andre´ and Vuyk³² identified septal battens and septal replacement. Gubisch³³ proposed removal of the entire septum, and subsequent extracorporeal septum reconstruction and reinsertion. This wide range of approaches shows how difficult it is to manage caudal septal deviations

Since the introduction of the swinging door techniquein 1929 by Metzenbaun ⁸, this technique and its variations have been the most commonly used used to correct nasal septum caudal deviations. In this type of correction, The caudal portion of the nasal septum with the deviation is not excised and the cartilage is mobilised by several incisions or weakened by incisions on the opposite side of the deviation, followed by sutures for stabilisation.

The criticisms against this form of technique state that by not having removed the deviated part of the cartilage, especially those in the region of the nasal valve, one would not correct the deviation adequately and the patient would continue to have nasal obstruction. Since the cartilage that has not been removed may have a memory, it continues to remain deviated or twisted after partial corrections according to Studies from Murakami et al.³⁴ which revealed the biomechanical properties of the septal cartilages and showed that partial incisions do not provide predictable corrections. Conservative corrections of caudal deviations would then be indicated only in those mild deviations. Our results show that there was no cosmetic change in relation to nasal tip or recurrence of the caudal septal deviation in all our cases of mild to moderate caudal septal deviation. Caudal septal deviation also can be corrected without any excision in the septum which may lead to droopy nose deformity ^35,36

The other methods that can be used to correct caudal deviations are the ones that eliminate part of the deviated cartilage, even if it supports the nasal tip, and inserts part of the autologous cartilage in its place to preserve the nasal structure. This type of technique was initially described by Peer¹⁶ in 1937.

The opponents of these techniques that remove the deviated cartilage claim that improvements in the structure of the nasal tip will not be preserved even after reconstruction. Another weakness found in these corrections with complete removal of the anterior septum would be that this technique is possible only via an open rhinoplasty , as defined by some authors ^20,21,37.

Stabilization of the repositioned caudal septum can also be performed using an tongue in-groove technique. Kridel³⁰ has described the septum being stabilised in a groove between the medial crurae. Suture is used in that pocket to stabilize the septum. He states that all patients in his series had good functional results at follow-up.

All patients noted improved airway function postoperatively. There was a significant improvement in mean Nasal Obstruction Symptoms Evaluation score postoperatively (35.5 +/- 15.80 VS 9.5 +/- 2.99). Thus, the results from the NOSE questionnaire carried out before surgery show a large incidence of obstruction complaints from those patients with deviations in their caudal septum ^6,7. The results as to the subjective improvement after surgery with the caudal septoplasty technique by the same questionnaire were also found in our study, similarly to what was found in other papers which measured per and post-operative patient satisfaction after correction of nasal septum deviations^22,38.

One disadvantage of TIG is the occasional rigid nasal tip complaint due to removal of the flexible membranous septum, as nasal base support is enhanced by bringing a three-layer cartilage structure together, we mentioned the tip rigidity during the consent process.

The concept of TIG is not innovative and with more widespread application of TIG in closed rhinoplasty surgery we only utilized it in cases of endonasal septoplasty through a hemitransfixtion incision, we also used both absorbable and non-absorbable sutures, we did not cut any excess mucosa, we only spread it back over the posterior septum then fixed it by a quilting suture to coapt the septal mucosa away from the skin of the columella avoiding weeping at the vestibule. The technique hereby described does not require specific surgeon knowledge about nasal aesthetics, it does not add any other incision or scar except for the same ones used for regular septoplasty and it does not increase the risk or likelihood of complications. There was no cosmetic complications and no patient complained of any changes regarding nasal tip during the ninety days follow up, of course longer period of follow up is being done

CONCLUSION

The results of our study subjectively indicate, through patient satisfaction, that applying tongue in groove technique endonasally for the correction of caudal septum deviation appears to be effective

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