RU2755975C1 - Method for correction of a caudal part of the nasal septum during secondary septoplasty - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.SUBSTANCE: for septoplasty, a graft is used obtained from residual material of the septum after previous operations. The detachment of the mucous septum is carried out. A bone-cartilage graft is taken by separating it from a nasal spine and a crest of the upper jaw ventrally. A septal cartilage is cut off with a section of a perpendicular plate as a single block dorsally. At the same time, strips of the septal cartilage with a height of 8 mm from above are preserved. Next, the graft is modeled in the form of an L-graft in height and shape. The bone segment is fixed to the treated nasal spine, and the cephalic edge is fixed to remains of the dorsal segment of the septum cartilage.EFFECT: method allows minimally invasive and minimally traumatic restoration of nasal breathing, minimizes the postoperative rehabilitation period.1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used during repeated operations to correct the caudal part of the nasal septum in case of its defect or curvature.

When performing septoplasty, it is a common surgical mistake to remove or damage the caudal part of the nasal septum, which is the frame for the dorsum of the nose and the caudal part of the nose. This leads to a loss of support for the tip of the nose, to its ptosis, dysfunction of the internal nasal valve, and as a consequence - a deterioration in nasal breathing. In addition, damage to the posterior septal cartilage often occurs, making it impossible to use it for reconstruction in repeated operations.

The task of the surgeon in secondary septoplasty is to restore the lost support of the tip of the nose, while the support material must meet the following requirements: be strong enough, even, have sufficient height and support ability.

Methods for correcting the caudal part of the nasal septum in repeated operations are implemented using suture and implantation techniques. Suture techniques are used in cases where there are preserved areas of the septal cartilage. Extensive defects in the caudal nasal septum force surgeons to seek alternative sources of plastic material for the reconstruction of the nasal septum.

A known method of surgical correction of the caudal nasal septum in secondary septoplasty, using the bone segment of the nasal septum: perpendicular plate of the ethmoid bone, vomer (Use of Nasal Septal Bone for Septal Extension Graft after Jaw Surgery. Kim, Gui Rak MD; Park, Kwangmin MD; Park, Kwangmin MD; Kim, Taegyu M D. Plastic and Reconstructive Surgery - Global Open: November 2013 - Volume 1 - Issue 8 - p e76, Jang YJ, Kim JM, Yeo NK, et al. Use of nasal septal bone to straighten deviated septal cartilage in correction of deviated nose Ann Otol Rhinol Laryngol 2009; 118: 488-494).

The disadvantage of this method is the difficulty of obtaining a relatively flat graft of the required size (due to curvature or possible removal of bone structures during previous operations). An increase in the operation time associated with the processing of the graft, the formation of the correct shape and the application of perforations for its fixation. Its partial resorption in the postoperative period is possible. The use of a bone graft stiffens the caudal part of the nose, which, in some cases, can cause patient discontent.

A known method of surgical correction of the caudal nasal septum in secondary septoplasty using an L-shaped cartilage graft from the costal cartilage, the cephalic edge of which is fixed to the remnants of the septal cartilage, to the upper lateral cartilage, or to the nasal bones, and the caudal end is sutured to the anterior nasal spine. (Converse JM et al. Corrective rhinoplasty. In Reconstructive plastic surgery (second edition). - Saunders WB Co, 1977; 2: 1040-1163. Paper A. D. Plastic and reconstructive surgery of the face: translation from English. - M. : BINOM. Laboratory of Knowledge, 2007. - 951 pp. Belousov AE Essays on Plastic Surgery. Volume 2. Functional Rhinoplasty. - Moscow: Polytechnic University Publishing House, 2010. - (367 pp.) 512 pp.).

The disadvantage of this method is the technical complexity, an increase in the operation time, additional surgical trauma with the preservation of a scar on the chest, an increase in the postoperative period. The rib graft is more difficult to model; in the postoperative period, it can be more often subjected to curvature, ossification and partial resorption. The use of a rib graft increases the stiffness of the nose.

The closest prototype method is the use of the posterior septal cartilage for the reconstruction of the caudal nasal septum (Toriumi D.M. Structura lapproach to primary rhinoplasty. Aesthetic Surg. J, 2002; 22 (1), 72-84.).

The disadvantage of the prototype method is that with repeated operations on the nasal septum, it is unlikely to obtain a sufficient graft in size, shape and strength. In the vast majority of cases, the remaining areas of the septal cartilage are damaged, thin, curved and small in size, which makes reconstruction impossible.

The aim of the present invention is the reconstruction of the lost support of the caudal part of the nose in order to restore nasal breathing.

The technical result in the invention is achieved by the fact that after detachment of the mucous septum, a bone-cartilaginous graft is taken by separating it from the nasal spine and the crest of the upper jaw ventrally, and cutting off the septal cartilage with a section of the perpendicular plate in a single block dorsally, while preserving a strip of septal cartilage 8 mm high from above, then the graft is modeled in the form of an L-graft in height and shape, fixed with a bone segment to the treated nasal spine, and with a cephalic edge to the remnants of the dorsal segment of the septal cartilage.

The proposed method is shown in the figure, where:

FIG. 1 - The original structure of the nasal septum, where:

1 - Septal cartilage

A - Ventral segment

B - Dorsal segment

2 - Perpendicular plate

3 - Nasal spine and crest of the upper jaw

FIG. 2 - Damaged nasal septum, after poor-quality operations, where:

1 - Septal cartilage

2 - Perpendicular plate

3 - Nasal spine and crest of the upper jaw

4 - Removed caudal septal cartilage

5 - Removed posterior septal cartilage

6 - Descent of the tip of the nose

FIG. 3 - Area of bone-cartilage graft collection, where:

1 - Septal cartilage

2 - Perpendicular plate

3 - Nasal spine and crest of the upper jaw

4 - Removed caudal septal cartilage

5 - Removed posterior septal cartilage

7 - Bone-cartilage graft

C - Long edge

D - Short edge

FIG. 4 - The final location of the bone-cartilage graft, where:

1 - Septal cartilage

2 - Perpendicular plate

3 - Nasal spine and crest of the upper jaw

7 - Bone-cartilage graft

C - Long edge

D - Short edge

8 - Raising the tip of the nose

The technique of the proposed method.

The proposed method is carried out as follows. In contrast to the original structure of the nasal septum (Fig. 1), where all its sections (1,2,3) are preserved, we meet with a damaged nasal septum, after poor-quality operations (Fig. 2), where the caudal part of the septal cartilage has been removed (4 ) and removed the posterior septal cartilage (5). A dorsal segment (B) and a weakly supported ventral segment (A) remain of the septal cartilage. After detachment of the mucous membrane of the nasal septum, a bone-cartilaginous graft (Fig. 3 (7)) is taken from the septal cartilage (1) preserved after previous interventions together with a section of the perpendicular plate of the ethmoid bone (2) as a single block. For this ventrally, the remaining part of the septal cartilage (1) is separated from the nasal spine and the crest of the upper jaw (3), dorsally cut off together with the segment of the perpendicular plate (2) in a single block, while preserving a strip of septal cartilage 8 mm high from above. Thus, we get a graft (7), in the form of an L - graft with a long upper edge (C), consisting of a strong dorsal segment of the cartilage septum and bone of the perpendicular plate, and a weak short vertical edge (D). Anatomically, the strength and width of the dorsal septal cartilage (B) is much higher than that of the ventral (A); therefore, the upper segment of the cartilage is advantageous to use as a supporting component of the graft.

The graft is modeled in shape and height, using cutters and suture techniques. The area of the nasal spine is processed with cutters, and perforations are applied to secure the vertical segment of the graft with sutures.

The next step is the installation of the bone-cartilage graft, making a rotation along the axis in the vertical plane and rotation in the sagittal plane (relative to its initial position (Fig. 4)). In this case, the strong upper, long edge of the graft (C) changes position to vertical, and the less strong short edge (D) to horizontal, and is fixed to the preserved strip of the dorsal segment of the septal cartilage. Fixation is performed with non-absorbable monofilament suture material (Nylon 5/0). Thus, a stable structure is obtained that strengthens the caudal part of the nose.

The length of the vertical segment of the L-graft controls the height of the tip of the nose (projection), and the function of the internal nasal valve, the main structure that regulates nasal breathing.

After completing the required amount of intervention, sutures are applied to the main incision.

The proposed method has been successfully tested in 16 patients with a diagnosis: Curvature of the nasal septum hospitalized in the Astrakhan branch of the Federal State Budgetary Institution of National Medical Research Center of the Federal Medical and Biological Agency of Russia for the period from 2017 to 2020.

Below is the result of testing.

Example # 1. Patient M., 25 years old, was admitted with the diagnosis: Curvature of the nasal septum, condition after septoplasty. Complaints upon admission for difficulty in nasal breathing. In the anamnesis of the disease - septoplasty 1.5 years ago, performed in another medical institution.

On examination, the external nose of the correct shape, the nasal bridge with a hump, long nasal bones. The tip of the nose is wide, rotated downward (hypoprojection), on palpation it is soft, mobile, a feeling of the absence of the anterior sections of the septal cartilage. Positive Cottle test on both sides. With anterior rhinoscopy: in the membranous part of the nasal septum on the left there is a postoperative scar, with palpation with a quilted jacket, the anterior sections of the septal cartilage are absent (up to 1 cm), in the area of the nasal spine there is a thin vertical plate of preserved, curved to the left cartilage. The ventral cartilage was also removed. The crest of the upper jaw and the opener are displaced to the left, the perpendicular plate and the upper preserved sections of the cartilage septum are displaced to the right.

Computed tomography of the paranasal sinuses revealed an S-shaped deviation of the nasal septum in the middle and posterior regions. The paranasal sinuses were without pathological changes.

Anterior active rhinomanometry revealed pathological abnormalities in quantitative indicators (total volume flow and total resistance to air flow), bilateral dysfunction of the internal nasal valves.

Taking into account the patient's complaints, anamnesis, objective data, and the results of computed tomography, secondary closed-access septoplasty was performed. Caudal access to the nasal septum. Detachment of the mucous membrane of the preserved part of the septal cartilage and the bony part of the septum. Correction of curved fragments of the posterior sections of the nasal septum - resection of the upper jaw ridge and vomer displaced to the left. Bone-cartilage graft was taken for reconstruction. For this, the ventral remaining part of the septal cartilage is separated from the nasal spine, dorsally cut off together with the segment of the perpendicular plate in a single block, while preserving the cartilage strip 8 mm high. above. Modeling the graft according to the size of the defect in the caudal part of the nasal septum: determining the height, aligning, and making perforations in the bone part of the L-graft for fixation. Treatment of the anterior spine, application of perforations on the nasal spine. Fixation of the bone segment of the L-graft to the anterior nasal spine using non-absorbable monofilament suture material (Nylon 5/0). The cephalic edge of the graft was fixed to the remnants of the dorsal segment of the septal cartilage with a PDS # 5 thread. Sutures were applied to the incision on the eve of the nasal cavity. Tamponade of the nasal cavity with Merocel tampons.

The postoperative period is smooth, the tampons from the nasal cavity were removed after 24 hours, the sutures were removed on the 14th day after the operation, healing by primary intention, the nasal septum in the midline, breathing is free.

At the control examination 6 and 12 months after the operation, the obtained results are preserved: the external nose of the correct shape, the tip of the nose with a sufficient projection, the septum in the midline, the respiratory function of the nose is restored, which is confirmed by the data of rhinomanometry.

The proposed method of surgical correction of the caudal part of the nasal septum in secondary septoplasty allows minimally invasive and less traumatic to obtain the result - to restore nasal breathing, and minimizes the postoperative rehabilitation period.

Claims (1)

A method for correcting the caudal part of the nasal septum in secondary septoplasty by using a graft obtained from the residual material of the septum after previous operations, characterized in that after detachment of the mucous septum, a bone-cartilaginous graft is taken by separating it from the nasal spine and the crest of the upper jaw ventrally and cutting off the septal cartilage with a section of the perpendicular plate in a single block dorsally with the preservation of a strip of septal cartilage 8 mm high from above, then the graft is modeled in the form of an L-graft in height and shape, fixed with a bone segment to the treated nasal spine, and with a cephalic edge to the remnants of the dorsal segment of the septal cartilage.

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