A, The bilateral mucoperichondrial flap is elevated without making an additional incision. B, The harvested septal bone is trimmed to adjust the length and width of the caudal septum and punctured with holes by drilling. C, The bony batten graft is placed against the concave side of the septum and fixed with a through-and-through suture. D, Fixation of the bilateral mucosa tightly to the corrected caudal septum using through-and-through sutures.
NOSE scores range from 0 to 100, with higher scores indicating greater obstruction. Postoperative scores were obtained at 6 months (P < .001). Error bars indicate SD.
Summary scores are shown before and 2 and 6 months after bony batten grafting for nasal obstruction in 141 patients. NOSE scores range from 0 to 100, with higher scores indicating more obstruction.
Preoperative (A) and postoperative (B) endoscopic findings. C, Computed tomography findings of bony batten grafting (arrow).
eTable 1. Variables for Primary vs Secondary Surgery Groups
eTable 2. Variables for Septoplasty+Turbinate vs Septoplasty Only Groups
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Kim D, Nam SH, Alharethy SE, Jang YJ. Surgical Outcomes of Bony Batten Grafting to Correct Caudal Septal Deviation in Septoplasty. JAMA Facial Plast Surg. 2017;19(6):470–475. doi:10.1001/jamafacial.2017.0092
What is the most effective surgical method to manage caudal septal deviation in septoplasty?
In this study of 141 patients undergoing septoplasty, all patients had significantly improved Nasal Obstruction Symptoms Evaluation scores postoperatively, and 128 patients (90.8%) had a straight septum on endoscopic examination for surgical outcome.
Septoplasty using bony batten grafts is useful for correcting caudal septal deviation, with favorable surgical outcomes and an acceptable complication rate.
Correction of caudal septal deviation with a batten graft has been popularized recently. However, few reports have documented the surgical outcomes of this technique, especially the use of bony batten grafts in septoplasty.
To evaluate the surgical outcomes of bony batten grafting for the management of caudal septal deviation in endonasal septoplasty.
Design, Setting, and Participants
This retrospective cohort study evaluates the medical records of 141 patients with caudal septal deviation who underwent septoplasty using bony batten grafts from September 1, 2011, through February 29, 2016, at a tertiary referral hospital. Patients were divided into primary and secondary surgery groups. Patients were also divided into the septoplasty plus turbinate surgery and the septoplasty only group. Endoscopic assessment of deviation correction was performed, and postoperative complications were analyzed.
Main Outcomes and Measures
Patient satisfaction and symptom improvement were evaluated via telephone interviews by using the Nasal Obstruction Symptoms Evaluation (NOSE) scores.
Of the 141 patients (24 women [17%] and 117 men [83%]; mean [SD] age, 32.8 [12.9] years), 86 (61%) rated their symptoms in the postoperative survey as much improved; 50 (35.5%), improved; 4 (2.8%), no change; and 1 (0.7%), worse. All patients had significantly improved mean (SD) postoperative NOSE scores (28.7 [22.0]; 95% CI, 25.0-32.4) compared with preoperative scores (70.5 [26.7]; 95% CI, 66.0-75.0; P < .001). No significant intergroup differences were observed in surgical outcome between the 116 patients undergoing primary surgery (mean [SD] NOSE score, 28.2 [21.9]) and 25 undergoing secondary surgery (mean [SD] NOSE score, 30.8 [24.3]; P = .34). No significant difference in surgical outcome was found between the 102 patients in the turbinate surgery group (mean [SD] NOSE score, 28.1 [20.8]) and 39 in the septoplasty only group (mean [SD] NOSE score, 30.4 [23.7]; P = .65). On endoscopic examination for surgical outcome, 128 patients (90.8%) had a straight septum and 13 (9.2%) had improved but residual caudal deviation. Postoperative complications included septal hematoma in 4 patients, hyposmia in 2, and chondritis in 1; all patients were treated successfully. Four patients required revision surgery because of incomplete functional correction or a desire for rhinoplasty.
Conclusions and Relevance
Septoplasty using bony batten grafts is useful for correcting caudal septal deviation with favorable surgical outcomes and an acceptable complication rate.
Level of Evidence
Nasal septal deviation is a major cause of nasal obstruction, and septoplasty is one of the most common procedures used for treating this condition. Many surgical methods, such as morselization, crosshatching incision, swing-door flap, partial-thickness incision, and anchoring suture, have been described to correct the deviated septum.1 However, caudal septal deviation is difficult to correct with these procedures because the intrinsic cartilage memory is hard to overcome. These techniques are also known to cause complications, such as weakening of the cartilages and overcorrection and subsequent nasal deformity. In addition, several studies2-4 have questioned the effectiveness of these techniques. Therefore, batten grafts have been introduced to stabilize the caudal septum and to prevent the occurrence of subsequent nasal deformities. Caudal septal batten grafting has been used more commonly in open rhinoseptoplasty and results in an improvement in nasal obstruction and nasal symptoms.5-7 However, patients with only caudal septal deviation need not undergo the incisional morbidity and additional surgical time of open rhinoseptoplasty.
Caudal septal batten grafting using septal cartilage via the endonasal approach has been reported to be a valuable technique for patients with no external nasal deformity.8-10 The septal bone removed during septoplasty can also be used as batten graft material. Although many reports have documented the use of septal cartilage grafts for correcting and stabilizing caudal septal deviation via the endonasal approach,8-11 few studies have reported the use of bony batten grafting with long-term follow-up and a large sample size.
We found caudal septal correction using bony batten grafts to be useful because the grafts exert a strong stenting effect that straightens and strengthens the deviated caudal septal cartilage. Thus, this study was designed to investigate the usefulness of bony batten grafting by focusing on the surgical outcomes, symptom improvement, and postoperative complications.
From September 1, 2011, through February 29, 2016, 141 patients presenting with caudal septal deviation were enrolled in this retrospective clinical study. In total, 187 patients who underwent bony batten grafting in septoplasty were investigated in this study. We subsequently excluded those who underwent concomitant procedures, including septal cartilage batten grafting, cutting and suture, and spreader grafting (n = 33), and those who underwent endoscopic sinus surgery (n = 13). Thus, 141 patients were finally eligible for inclusion in our study. All surgical procedures were performed by one of us (Y.J.J.). Bony batten grafting was performed in patients with generalized C-shaped caudal septal deviation without any angulations or dislocation of the caudal septum from the anterior nasal spine. All patients included in the study were at least 15 years of age, underwent primary or secondary septoplasty with bony batten grafting, and experienced nasal obstruction for longer than 3 months. This study was approved by the institutional review board of the Asan Medical Center, Seoul, South Korea, which waived the need for informed consent. All data were deidentified after data collection.
We reviewed the medical records to obtain clinicodemographic data, preoperative and postoperative nasal endoscopic findings, and data on postoperative complications and concomitant surgical procedures performed during endonasal septoplasty. Caudal septal deviation was diagnosed using nasal endoscopy performed by one of us (Y.J.J.). The postoperative status of the nasal septum was classified as 1, indicating straight; 2, improved but with residual deviation; or 3, no change compared with the preoperative appearance or severe deviation.
Nasal Obstruction Symptoms Evaluation (NOSE) scores were collected preoperatively and at the 2- and 6-month follow-up visits. Higher NOSE scores indicated worse nasal obstruction (range, 0-100). We used the validated NOSE scores for self-reported symptoms of nasal obstruction.12 In addition to the NOSE scores, patients were asked to assess their surgical outcome in terms of nasal obstruction as much improved, improved, or no change via telephone interviews performed at 6 to 61 postoperative months (mean, 31.1 months).
We compared the surgical outcomes of the groups undergoing primary and secondary surgery. We also divided patients into those who underwent turbinate surgery and those who underwent septoplasty only to compare the effect of additional turbinate surgery.
All procedures were performed under general anesthesia. A unilateral hemitransfixion incision was made 2 to 3 mm behind the caudal region of the concave side of the nasal cavity via the endonasal approach. The entire caudal border of the septum from the anterior septal angle down to the anterior nasal spine was exposed by this incision. Through the incision, a complete elevation of the ipsilateral septal mucoperichondrium to the posterior part of the bony septum was completed. Thereafter, the mucoperichondrium on the contralateral side was elevated without making an additional incision; instead, the elevation was performed by crossing over to the contralateral side through the incision made previously (Figure 1A). Mucosal elevation on the convex side was performed until the point just posterior to the maximally convex part. The curved portion of the septal cartilage and bone was harvested after preserving a portion of the L-strut of the dorsal and caudal cartilaginous septum at least 1.5 cm in length. After bilateral flap elevation, subperichondrial dissection into the nasal floor was performed to the extent that a bony graft could be inserted. The excised septal bone was trimmed to adjust the length and width of the caudal septum and punctured with holes by drilling so that it could be easily sutured to the caudal septum (Figure 1B). The caudal septal batten graft created from the harvested septal bone was fitted to the desired location, usually on the concave side (but on both sides if concerns about graft tilt were present), and fixed with 5-0 polydioxanone sutures (Ethicon Inc) (Figure 1C). The size and amount of harvestable septal bone should be sufficient to cover the full length of the caudal septum in cases of primary and secondary surgical procedures. We did not intend to gain additional tip projection by designing the batten graft to not extend beyond the caudal or anterior limit of the caudal septum. The gap between the posterior portion of the caudal septal bony batten graft and the caudal septum was closed using 1 or 2 through-and-through transcartilage and transbony sutures (5-0 polydioxanone sutures). The hemitransfixion incision was closed using 6-0 chromic gut sutures (Ethicon Inc), and 2 or 3 through-and-through transmucosal sutures (4-0 chromic gut sutures) were used to fix both mucosae tightly to the newly created caudal septum (Figure 1D). The surgery was completed once we confirmed the straightening of the deviated caudal septum. Some patients with compensatory inferior turbinate hypertrophy, including grades II (moderate enlargement with obvious obstruction) and III (complete occlusion of the nasal cavity),13 underwent some form of volume reduction of the inferior turbinate, such as radiofrequency volume reduction (n = 89), outfracture (n = 11), or submucosal resection (n = 2). Finally, 1-mm–thick silicone nasal splints were inserted into both nasal cavities and fixed by suturing to the nasal septum.14 These splints were removed about 5 to 6 days later in the outpatient clinic department.
Statistical analysis was performed using SPSS for Windows (version 12.0; SSPS Inc). For quantitative variables, the values are presented as mean (SD). Wilcoxon signed rank test was used to compare the preoperative and postoperative NOSE scores. Differences were considered to be statistically significant at P < .05.
Of the 141 patients included in the case series (24 women [17%] and 117 men [83%]; mean [SD] age, 32.8. [12.9] years), 116 (82.3%) underwent a primary septoplasty and 25 (17.7%) underwent a secondary surgery. The mean (SD) follow-up period was 7.6 (7.5) months; however, 61 patients (43.3%) had follow-up periods longer than 1 year (Table).
Analysis of the subjective outcome questionnaires completed postoperatively showed that 86 patients (61%) reported that their nasal obstruction was much improved; 50 (35.5%), improved; 4 (2.8%), no change; and 1 (0.7%), worsening of the condition. When we compared the surgical outcomes of the primary (n = 116) and secondary (n = 25) surgery groups, no significant intergroup differences were observed in the mean NOSE scores (28.2 [21.9] vs 30.8 [24.3]; P = .34), patient satisfaction (much improved, 71 [61.2%] vs 15 [60%]; P = .89), complication rates (5 [4.3%] vs 2 [8%]; P = .44), and revision rates (3 [2.6%] vs 1 [4%]; P = .70) (eTable 1 in the Supplement). We also compared the surgical outcomes of the groups undergoing septoplasty plus turbinate surgery (n = 102) and septoplasty only (n = 39). We found no significant difference in mean NOSE scores (28.1 [20.8] vs 30.4 [23.7]; P = .65), patient satisfaction (much improved, 62 [60.8%] vs 24 [61.5%]; P = .69), complication rates (5 [4.9%] vs 2 [5.1%]; P = .95), and revision rates (3 [2.9%] vs 1 [2.6%]; P = .90) (eTable 2 in the Supplement).
The mean postoperative NOSE scores were significantly lower than the preoperative scores, indicating a significant improvement in nasal obstruction. For the 141 patients, the mean (SD) preoperative NOSE score was 70.5 (26.7; 95% CI, 66.0-75.0), and the mean (SD) postoperative NOSE score was 28.7 (22.0; 95% CI, 25.0-32.4; P < .001) at the 6-month follow-up (Figure 2). To identify the outcome in a time-ordered sequence, we analyzed the NOSE scores for these patients over time. The improvement in the postoperative NOSE scores was evident at the 2-month follow-up and remained stable over time until the 6-month follow-up (P < .001) (Figure 3).
An analysis of the postoperative endoscopic findings showed that 128 patients (90.8%) had a straight septum. However, 13 patients (9.2%) had improvement with residual deviation, although their septal deviation had improved more than their preoperative septal status. None of the patients had septal deviation similar to or worse than the preoperative level.
Postoperative complications included septal hematoma in 4 patients, chondritis in 1, and hyposmia in 2. All cases of septal hematoma were detected in the posterior septum within 2 weeks after surgery. Patients with hyposmia were treated with oral methylprednisolone for 14 days (32 mg once daily for the first 2 days, 28 mg once daily for 2 days, and tapering for 10 days); patients with chondritis were treated with oral gemifloxacin mesylate (320 mg once daily for 5 days); and patients with septal hematoma were treated using an incision and drainage, followed by gauze packing after 3 to 5 days and administration of oral gemifloxacin mesylate (320 mg once daily for 5 days). Revision surgery was performed in 4 patients because of recurrence or complaint of nasal obstruction during the follow-up period. Of these 4 patients, 3 underwent rhinoplasty because they expressed a desire for aesthetic improvement and improvement of nasal obstruction due to postoperative residual septal deviation. In 1 patient, the cutting and suture procedure was performed by replacing the previously located batten graft under local anesthesia. All patients who underwent revision surgery were satisfied with the improvement of symptoms (eTable 1 in the Supplement).
In this study, we found that septoplasty using bony batten grafting was quite effective in improving patients’ symptoms. Batten grafting on the caudal septum is one of the most effective methods for correcting the caudal septum when it is too weak or severely deviated.8,9,15 A previous study9 showed a 90% improvement in nasal obstruction after endonasal septoplasty using a caudal septal batten created from harvested septal cartilage for caudal septal deviation correction. Chung et al8 reported the use of bony batten grafting and demonstrated a postoperative improvement in visual analog scale scores and acoustic rhinometry in 39 patients with caudal septal deviation. In that study, the investigators separated the anterior nasal spine and septal cartilage in all cases, followed by suturing along with the bony batten graft. The bony batten graft was designed to partially cover the inferior portion of the caudal septum. Our technique is somewhat different from that used by Chung et al8 in that we did not separate the septal cartilage from the anterior nasal spine. The bony batten graft was trimmed to cover the entire length of the caudal septum and was fitted to the concave side. We believe that maintaining the caudal septal attachment to the anterior nasal spine is very important while performing bony batten grafting unless the caudal septum is dislocated from the anterior nasal spine.
Moreover, in contrast to the small sample size (39 patients) in the report by Chung et al,8 our study enrolled 141 patients with caudal septal deviation and analyzed the surgical outcome of bony batten grafting, including patient satisfaction, improvement of symptoms by using the NOSE score, endoscopic findings, and associated complications. We also compared the surgical outcomes of the primary and secondary surgery groups and demonstrated no significant intergroup differences in outcomes. This finding further supports the usefulness of bony batten grafting as a secondary surgery in which the weakened caudal septal support after prior surgery can be stabilized and straightened because of the stenting effect of bony batten grafting. Moreover, to assess the effect of concurrent turbinate surgery, we compared the surgical outcomes of the septoplasty plus turbinate surgery and the septoplasty-only groups. However, we found no significant difference between the groups. This finding had also been reported in another study, which showed no statistical significance of an increased minimal cross-sectional area and symptomatic improvement in the patients who were treated with septoplasty and concomitant turbinate surgery.10
In our study, patients with persistent nasal obstruction showed a statistically significant postoperative improvement in NOSE scores at 2 months. No statistically significant difference was observed between the 2- and 6-month NOSE scores, suggesting that the postoperative improvement in NOSE scores was stable and sustained from 2 to 6 months. This result was similar to that of previous reports analyzing the preoperative NOSE scores and the scores at 3 and 6 months after the secondary or primary septoplasty.16,17
The use of septal bony batten grafting has notable advantages. First, the septal bone has a very low possibility of influencing nasal airflow by adding too much volume on the caudal septum because the harvested bone is usually thin and does not add too much thickness to the native caudal septal cartilage. The septal cartilage is a useful graft material in batten grafting to correct caudal septal deviation; however, the thickness of the graft might influence the external nasal valve and columellar width. If the septal bone is thick, it can be easily thinned by drilling. Second, the rigid nature of a bony batten graft allows the surgeon to maintain the straightness of the caudal septal cartilage. Unlike the bony batten graft, a cartilage batten graft can be bent because of the cartilage memory of the native caudal septum. Third, the use of a bony batten graft can avoid the use of the septal cartilage as a batten graft. If the caudal septum could be straightened by using a bony batten graft, we did not use the harvested septal cartilage; instead, we saved it by reimplanting it in the central portion of the nasal septum for possible later use.
In the present study, 4 patients developed septal hematoma and 1 developed chondritis after septoplasty. Septal hematoma occurred mostly from the posterior nasal cavity where the bony septum was harvested. Unrecognized or delayed bone bleeding might have predisposed the patients to this complication. When hematoma is detected during follow-up, it is easily manageable by making a small incision at the septal mucosa, followed by hematoma evacuation and gauze packing. We encountered 1 case of chondritis that might have resulted from the use of too much suture material for fixing the batten graft, bilateral flap dissection, or transmucosal sutures. We also encountered 2 cases of hyposmia, which was temporary in both cases. The hyposmia might have resulted from ischemic insult on the olfactory epithelium because of tight gauze packing.18
Use of the bone on the caudal septum can make the caudal septum and nose too stiff, which is anatomically unnatural. Therefore, complications such as the sensation of a highly rigid nose may occur; however, in our case series, none of the patients complained about this expected complication. The absence of this complication was probably attributable to the intrinsic weakness of the Asian septal cartilage, which was reinforced by the bony batten graft in a more favorable manner.
The major concern regarding the use of the septal bone in nose surgery is the possibility of bone resorption and subsequent recurrence of deviation. However, previous studies6,8,19 have shown the persistence and stability of bone grafts in the nose. Moreover, none of the patients in the present study had any recurrence. In a patient with clinically suspected sinusitis 1 year after septal batten grafting, we could also identify an intact bone maintaining the straight septum at computed tomography and endoscopic examinations (Figure 4). Mucosal erosion secondary to bony exposure can be another possible complication. However, we avoided this complication by maintaining robust mucoperichondrial flap during mucosal dissection.
Our study has some noteworthy limitations. First, it was a retrospective study with no randomization of the study population. Second, we did not use objective airway measurements, such as acoustic rhinometry or rhinomanometry, for analyzing the anatomical features of the caudal septum.
The present study has shown favorable surgical outcomes with the use of bony batten grafting in septoplasty. We suggest that septoplasty using bony batten grafting is a useful technique for the correction of caudal septal deviation, with favorable surgical outcomes and acceptable complication rates.
Corresponding Author: Yong Ju Jang, MD, Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-2dong, Songpa-gu, Seoul 138-736, South Korea (email@example.com).
Accepted for Publication: January 15, 2017.
Published Online: May 18, 2017. doi:10.1001/jamafacial.2017.0092
Author Contributions: Drs Kim and Jang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kim, Jang.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: Kim, Jang.
Statistical analysis: Kim, Alharethy.
Obtained funding: Alharethy, Jang.
Administrative, technical, or material support: Kim, Alharethy.
Study supervision: Jang.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by International Scientific Partnership Program grant 007 from King Saud University.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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