Surgical Atlas of pediatric otolaryngology - part 4 doc

The rior ethmoidal artery supplies the anterior third of the lateral nasal walland adjacent septum, whereas the posterior ethmoidal artery suppliesthe superior turbinate, posterior super

246 Surgical Atlas of Pediatric Otolaryngology

• An intraoperative portable X-ray is strongly advised to verify trode placement while the patient is still asleep The patient’s head isstraightened on the table, preferably prior to application of the dress-ing A single anteroposterior transorbital view (slightly over-penetrat-ed) is taken (Figure 9–20) An incorrectly placed or compressed elec-trode should be discovered in the operating room rather than weekslater when the child is found to be nonstimulable

elec-• A gentle mastoid dressing is applied

Figure 9–20 An intraoperative

transorbital X-ray is taken to

verify electrode position

A, Straight electrode B,

Peri-modiolar electrode.

B

A

• MRI must be avoided unless the magnet can be removed (as with theNucleus CI 24 series); there is no contraindication to CT scanning.

• Monopolar cautery should never be used in the vicinity of the cochlearimplant or in cases where the implant lies between the active and theground electrodes Other forms of radiant energy (eg, diathermy) shouldalso be avoided, as well as plastic playground slides while the external hard-ware is being worn

Complications

• No deaths or life-threatening surgical complications have been reportedafter cochlear implantation, and the complication rate has decreasedover the years (Table 9–1) Complications for children are less than foradults (Table 9–2)

Table 9–1 Cochlear implant complications over time (for both adults and children)

Table 9–2 Cochlear implant complications in adults vs children

Type of complication Adults (%) Children (%)

248 Surgical Atlas of Pediatric Otolaryngology

• Major complications include facial palsy and others requiring talization for surgery or intravenous antibiotics

re-hospi-♦ The most common major complications include flap necrosis orinfection, migration of the device and/or electrode, and electrodemisplacement or damage, many of which might have been avoided bymore appropriate planning and surgical technique

♦ A displaced cochlear implant electrode detected by an intraoperativeX-ray would be replaced without delay or a second operation

♦ Most cases of facial palsy occur shortly after surgery, but others may

be delayed until well after discharge Most are probably caused bythermal injury from the bur-shaft when drilling the facial recess orcochleostomy, rather than direct trauma to the nerve Most resolvecompletely

• Minor complications are those handled in an outpatient setting; no nificant increase in morbidity occurs

sig-• Finally, there has not been an increased incidence of otitis media in dren who have received cochlear implants, complications caused by thepresence of the implant, or the loss of an implant secondary to otitis media

chil-CONCLUSIONS

Cochlear implant surgery in children can be accomplished satisfactorily andsafely in the overwhelming majority of properly selected candidates Thesurgery requires some modifications from the adult technique, especially inthe child under age 2 years, but the complication rate is not greater Aftermore than a decade of experience, there does not appear to be a deleteriouseffect on the middle or inner ear from implanting a multichannel cochlearimplant in children The benefit of these devices, on the other hand, hasbeen even greater than anticipated, even in the very young congenitally deafchild Unexpectedly, many older congenitally deaf children have alsoreceived significant demonstrable benefit from cochlear implantation

Clark GM, Cohen NL, Shepherd RK Surgical and safety considerations of multichannel cochlearimplants in children Ear Hear 1991:12 Suppl 4:15S–24S

Cohen NL, Hoffman RA Complications of cochlear implant surgery In: Eisele DW, editor plications in head and neck surgery St Louis: Mosby-Year Book; 1993 p 722–9

Com-Cohen NL Surgical techniques to avoid complications of cochlear implants in children Adv Rhino-Laryngol 1997;52:161–3

Oto-Cohen NL Surgical techniques for cochlear implants In: Waltzman SB, Oto-Cohen NL, editors.Cochlear implants New York: Thieme; 2000 p 151–6.

Fishman AJ, Holliday RA Principles of cochlear implant imaging In: Waltzman SB, Cohen NL,editors Cochlear implants New York: Thieme; 2000 p 79–107

Hoffman RA, Downey LL, Waltzman SB, Cohen NL Cochlear implantation in children withcochlear malformations Am J Otol 1997;18:184–7

Hoffman RA, Cohen NL Complications of cochlear implant surgery Ann Otol Rhinol Laryngol1995;166 Suppl:420–2

Kveton J, Balkany TJ Status of cochlear implantation in children American Academy of gology – Head and Neck Surgery Subcommittee on Cochlear Implants J Pediatr1991;118:1–7

Otolaryn-Lenarz T, Battmer RD, Bertram B Cochlear implantation in children under 2 years of age In:Waltzman SB, Cohen NL, editors Cochlear Implants New York: Thieme; 2000 p 163–5.Roland JT Jr, Fishman AJ, Alexiades G, Cohen NL Electrode to modiolus proximity: a fluoroscop-

ic and histologic analysis Am J Otol 2000;21:218–25

Roland JT Jr, Fishman AJ, Waltzman SB, et al Stability of the cochlear implant in children, goscope 1998;108:1119–23

Laryn-Shpizner BA, Holliday RA, Cohen NL, et al Postoperative imaging of the multichannel cochlearimplant Am J Neuroradiol 1995;16:1517–24

Waltzman SB, Cohen NL Cochlear implantation in children younger than 2 years old Am J ogy 1998;19:158–62

Otol-Webb RL, Lehnhardt E, Clark GM, et al Surgical complications with the cochlear nel intracochlear implant: experience at Hannover and Melbourne Ann Otol Rhinol Laryn-gol 1991;100:131–6

multiple-chan-E PISTAXIS Scott C Manning, MD

ANATOMY

• The most common site of nasal bleeding in children is the anterior tum, where several terminal branches of both the internal and externalcarotid systems come together under a thin delicate mucosa Kiessel-bach’s or Little’s area is also the part of the nose that is most likely to beadversely affected by trauma and dry air (Figure 10–1)

sep-• Superior epistaxis usually involves terminal branches of the anterior or

posterior ethmoidal arteries (Figures 10–1 and 10–2), which are

branch-es of the ophthalmic arteribranch-es from the internal carotid system The rior ethmoidal artery supplies the anterior third of the lateral nasal walland adjacent septum, whereas the posterior ethmoidal artery suppliesthe superior turbinate, posterior superior lateral nasal wall, and septum.These arteries may be injured during endoscopic sinus surgery

ante-Most epistaxis in children is caused by anterior septal trauma from digital manipulation,nose rubbing (allergic salute), or blunt injury Predisposing factors include dry winter air,frequent upper respiratory infections, and allergic, viral, or bacterial rhinitis

Unilateral epistaxis and nasal obstruction in a young child should prompt a carefulexamination for a foreign body Infrequently, obstruction from septal deviation or polypsmay create focal areas of mucosal drying and ulceration Vascular tumors, such as rhab-domyosarcomas in young children or angiofibromas in adolescent boys, are a rare cause ofdramatic difficult-to-control epistaxis Appropriate radiographic evaluation, such as com-puted tomography, is indicated when tumors are suspected

Local cautery is sufficient to control most epistaxis in children; posterior packing anddirect vessel ligation are rarely necessary For extremely refractory epistaxis, especially inpatients with primary or acquired coagulopathies, selective embolization of involved vesselscan be performed by an experienced interventional radiologist The most common com-plication of selective embolization is transient facial nerve weakness; tissue ischemia is rare

Epistaxis 253

LOCAL CAUTERY

Indications

• Identified focal bleeding site on the anterior septum

• Bleeding unresolved with 5 minutes of continuous local pressure vianose pinching

• Bleeding refractory to medical therapy, including allergy managementand application of petroleum-based ointment to the anterior septum

Anesthetic Considerations and Preparation

• Topical anesthesia and vasoconstriction are achieved with cotton gets or applicators soaked in lidocaine and oxymetazoline; alternatively,4% cocaine solution can be sprayed

pled-• The nasal cavity is inspected carefully with a headlight and speculum,microscope, otoscope, or rigid endoscope

• Gentle suctioning and nose blowing are performed to remove all bloodand clots

• Antibiotic ointment is applied to the cautery site

ANTERIOR PACKING

Indications

• Failure of local cautery

• Diffuse mucosal bleeding sites

• Coagulopathy

Anesthetic Considerations and Preparation

As described above—see Local Cautery.

Procedure

• Working from inferior to superior with a headlight and pediatric nasalspeculum, small strips of absorbable packing (oxidized cellulose or gelatinsponge) coated with small amounts of antibiotic ointment are placed

• Alternatively, ointment-coated gauze or cotton strips are layered frominferior to superior This method may cause further mucosal irritationwhen the gauze is removed

• When possible, permanent packing should not be used in patients withsevere coagulopathy because inflammation and mucosal trauma whenthe packing is removed are likely to result in further bleeding

Postoperative Care

• Following successful management of routine anterior septal bleeding,preventive measures include humidification with topical nasal salineand/or room humidifiers and application of petroleum-based ointments

to the distal septum

• Steroid-containing ointments can be used for up to 2 weeks to morerapidly control inflamed vessels in the caudal septum

• General management of suspected allergic rhinitis can help preventrecurrent epistaxis by reducing trauma from facial rubbing and by reduc-ing mucosal inflammation

ENDOSCOPIC-GUIDED CAUTERY Indications

• Failure of anterior packing

• Cooperative patient

Anesthetic Considerations and Preparation

As described above—see Local Cautery.

the rigid endoscope used to

visu-alize the posterior nasal cavity.

Epistaxis 255

POSTERIOR PACKING Indications

• Epistaxis caused by an identified posterior (sphenopalatine area) bleed

• Posterior epistaxis caused by facial fractures, severe coagulopathies, orsinus surgery

Anesthetic Considerations and Preparation

As described above—see Local Cautery.

Procedure

• Manufactured nasal balloons may be placed in the nasal cavity andinflated as per instructions below (Figure 10–4)

• A posterior pack can be fashioned from a 15-mL urinary catheter:

♦ Cut a 1- to 2-cm length segment of endotracheal tube of a size thatwill slide over the urinary catheter back to the insufflation ports

♦ Place the urinary catheter through the nose so that its tip is visualizedjust beyond the soft palate on oral examination

♦ Inflate the balloon with 5 to 10 mL of sterile saline

♦ Place an anterior nasal pack around the catheter with either gauze or

absorbable hemostatic material (see Anterior Packing, above).

♦ Slide the “sleeve” forward so that it fits within the nostril and putspressure against the anterior pack

♦ Put tension on the posterior balloon by pulling the catheter forwardwhile placing countertraction against the sleeve

♦ Add further saline to the posterior balloon as necessary to stop allbleeding

♦ Fix the catheter in place by placing a C clamp (or other type ofclamp) on the catheter just in front of the sleeve

Figure 10–4 Demonstration of

a manufactured epistaxis

bal-loon The posterior balloon in

the nasopharynx provides an

anchor for the anterior balloon

to apply pressure to the posterior

nasal cavity.

• Gauze packs also can be used for posterior packing (Figure 10–5):

♦ Fix a gauze pack to a catheter passed through the nose and retrievedthrough the mouth

♦ Pull the gauze pack, via a suture, firmly against the posterior choanalopening

♦ Place an anterior nasal layered gauze pack and fix the posterior packsuture to a soft rubber or gauze bolster outside the nares

♦ In young children it may be advisable to use absorbable packing, assurgical gauze may adhere and be difficult to remove in the uncoop-erative child

• An endoscopic-guided direct cautery can be attempted, as describedabove

Postoperative Care

• For unusually severe posterior bleeding episodes requiring bilateral nasalpacking, the child is admitted to the hospital, if not already hospitalized.Continuous pulse oximetry monitoring is used to detect hypoxia, par-ticularly during sleep Supplemental oxygen is used as needed

• Nasal packs may injure the septal mucosa, with resultant bleeding whenpacks are removed (especially for children with systemic coagulopathies)

• The packs are checked for excessive pressure to the columella nasi andala nasi, which may result in ischemic injury if prolonged

Figure 10–5 A, Fixing of a suture attached to a posterior gauze pack to a catheter placed around the palate B, An anterior pack

of layered antibiotic-coated gauze A suture from a posterior pack is affixed to a soft bolster outside the nares (Modified from Culbertson MC, Manning SC Epistaxis In: Bluestone CD, Stool SE, editors Pediatric otolaryngology 2nd ed Philadelphia:

WB Saunders; 1990 p 675.)

Epistaxis 257

ARTERIAL LIGATION

Older techniques of transantral approach to the internal maxillary artery ortransethmoidal approach to the anterior and posterior ethmoidal arteriesare being replaced by endoscopic approaches to the terminal branches ofthe respective arteries

Indications

• Epistaxis refractory to more conventional treatment

• Epistaxis caused by severe facial fractures

• Epistaxis caused by neoplasms of the face or paranasal sinuses

Anesthetic Considerations and Preparation

• General anesthesia with a hypotensive technique is used if possible

• Local injection of the greater palatine foramen can allow for better alization by temporarily reducing the bleeding

visu-• Anterior and posterior packs are removed, and the nasal cavities are tioned and treated with oxymetazoline

Moreau S, DeRugy MG, Babin E, et al Supraselective embolization in intractable epistaxis: review

of 45 cases Laryngoscope 1999;108:887–8

Murthy P, Nilssen EL, Rao S, McClymont LG A randomized clinical trial of antiseptic basal

carri-er cream and silvcarri-er nitrate cautcarri-ery in the treatment of recurrent antcarri-erior epistaxis Clin laryngol 1999;24:228–31

Oto-Murray AB, Milner RA Allergic rhinitis and recurrent epistaxis in children Ann Allergy AsthmaImmunol 1995;74:30–3

Wormald PJ, Weed TH, van Hasselt CA Endoscopic ligation of the sphenopalatine artery for tory posterior epistaxis Am J Rhinol 2000;14:261–4

refrac-CH A P T E R 11

Jon B Turk, MD William S Crysdale, MD

PRINCIPLES OF NASAL SURGERY

• Older teenagers (males age 16 years or older, females age 14 years orolder) are treated no differently than adults because beyond this agethere is very little significant facial skeletal growth

• Adolescents being considered for aesthetic nasal surgery must also havepsychological and emotional factors addressed with both themselves andtheir families

• Children younger than age 15 years should have surgery performedusing the least destructive techniques to accomplish the surgical goal;nasal and septal cartilage should be reshaped and repositioned ratherthan removed

• Techniques that rely on sutures to reposition and control the nasal tipare often performed through the external approach, and are especiallyuseful in pediatric rhinoplasty, owing to their nondestructive nature andreversibility

• Bony osteotomies, when necessary, should be performed with smallsharp osteotomes to minimize bone loss and trauma to surrounding tis-sues The periosteum overlying the nasal bones should always be pre-served to prevent collapse of the nasal bones with resultant pyriformaperture and internal nasal valve stenosis

Pediatric nasal surgery is performed for functional, aesthetic, and reconstructive reasons.Contrary to certain widely held beliefs, nasal surgery can be performed safely at almost anyage if appropriate cartilage-sparing and suture-control maneuvers are employed Failure totreat symptomatic pathology because of concerns over interrupting facial growth can pro-long functional and aesthetic problems Whereas a healthy respect for facial growth centersshould accompany any otolaryngologic intervention in children, surgical correction ofstructural nasal obstruction and deforming injuries should not be “deferred” until the lateteen years

Computed tomography (CT) scanning is the preferred radiographicmethod for nasal pathology Plain radiographs are not recommendedbecause fractures and cartilaginous deformities are poorly visualized Incontrast, CT scans demonstrate bony and cartilaginous deformities andprovide information on the orbit, facial bones, and paranasal sinuses.Although not every patient requires radiographic imaging for diagnosis,

CT scans serve to document pathology, aid surgical planning, and surveyadjacent structures

The otolaryngologist performing septal and nasal surgery should tain a dedicated septorhinoplasty tray with sharp rasps and osteotomes Alightweight adjustable headlight with a halogen or xenon light source should

main-be routinely worn main-because overhead lights are inadequate for intranasal alization Finally, a dry operative field is essential for all nasal procedures,which is best accomplished by infiltrating the nose and septum with localanesthetic and vasoconstrictor 10-15 minutes before the start of surgery

visu-CLOSED REDUCTION OF NASAL FRACTURE

Closed reduction is a minimally invasive technique used to reduce simplelaterally displaced nasal fractures within 2 weeks of the onset of injury.Closed reduction is ideally performed when swelling has subsided, butbefore fibrosis and bony union has begun This “window of opportunity”

is typically between 5-10 days following the injury

While it may be appropriate to wait several days to reduce a nasal ture, the nose must be examined professionally prior to that time to detectseptal hematoma If a septal hematoma is diagnosed it should be incisedand drained immediately (Figure 11–1), usually under general anesthesia

frac-A septal quilting stitch is placed (Figures 11–2frac-A and B) and nasal packs are

inserted bilaterally This may prevent more serious sequelae such as septalabscess and saddle nose deformity

Figure 11–1 The

mucoperi-chondrium is incised with a No

11 scalpel blade.

262 Surgical Atlas of Pediatric Otolaryngology

Procedure

• Well wrung-out pledgets sprayed with oxymetazoline are gently insertedinto the patient’s nose after anesthesia induction is begun

• No local anesthesia is injected into the nose so as to prevent distortion.

• A small Goldman displacer, or other blunt instrument such as the back

of a knife handle, is gently inserted into the nostril on the side of theinwardly displaced fracture (ie, the side where the nasal bone is fractured

toward the septum) (Figure 11–3A)

• The surgeon’s contralateral hand is placed on the skin overlying the wardly displaced fracture (ie, the side where the nasal bone is fracturedaway from the septum) Depending on which way the nose is fractured,the surgeon will rest the thumb or forefingers of the contralateral hand

out-on the external surface of the patient’s nose

• With both the displacer and the contralateral thumb or fingers moving in

unison, the surgeon performs a fluid two-part movement (Figure 11–3B):

1 A downward movement (towards the patient’s toes) is used to distractthe fractured nasal bones

2 A sideways movement is used to simultaneously outfracture the inwardly displaced nasal bone and infracture the outwardly displaced

nasal bone; a “click” is often heard as the nasal pyramid moves intoproper position

• While considerable force may be necessary to reposition the fracturedsegments, the operator should be careful not to use so much force as tofracture or displace the nasal septum or upper lateral cartilages

• By carefully inserting, manipulating, and withdrawing the Goldman placer, mucosal laceration can be avoided and the procedure remainsessentially bloodless

dis-• A nasal splint is then applied to the newly aligned nasal bones; intranasalpacking is utilized only if there has been significant bleeding, which isextremely rare if closed reduction has been performed correctly

Postoperative Care

• If utilized, nasal packing is removed on the first postoperative day

• Ice packs over the eyes are recommended for the first 48 hours

• The nasal splint can be removed on the seventh postoperative day

• Gentle nasal “exercises” are begun in order to maintain bony alignment.These are accomplished by having the patient (or a parent) gentlysqueeze the nasal bones together a few times a day for the first seven daysafter the splint comes off Pressure should be light, and the patientshould not experience pain during this maneuver

• The patient may resume light aerobic activity after 2 weeks, running andjumping at 4 weeks, and has no restrictions after 6 weeks

Septoplasty eliminates nasal septal pathology interfering with normal nasalfunction Most children with nasal septal pathology have nasal obstruction,which is a nonspecific and common complaint The differential diagnosis

of pediatric nasal obstruction also includes sinusitis, allergic rhinitis, andadenoid hyperplasia, which may coexist with a septal problem In addition

to anterior rhinoscopy, the diagnostic evaluation may require rhinometry,flexible endoscopy, or imaging studies to determine the etiology of nasalobstruction

Septoplasty can either be completed using an internal approach or an

external approach The internal approach offers low morbidity, but is

suit-able only for pathology limited to the posterior inferior aspect of the nasal

septum The external approach has higher morbidity, but facilitates

prima-ry or revision surgeprima-ry for all types of septal pathology, including large tilaginous defects (ie, necrosis after a septal abscess)

car-INTERNAL APPROACH FOR SEPTOPLASTY Indications

• Nasal obstruction caused by septal pathology posterior and inferior to aline from the anterior nasal spine to the caudal aspect of the nasal bones

(Figures 11–4A and B).

• To facilitate access to the nasal cavity when completing other nasalsurgery (ie, polypectomy, endoscopic sinus surgery)

Figure 11–4 A, The stippled area represents the location of the septal pathology Note that it is posterior to a line joining the anterior nasal spine and the anterior aspect of the nasal bones B, The view of septal pathology with anterior rhinoscopy

QC = Quadrilateral cartilage

Nasal and Septal Deformities 265

Contraindications

• Mucosal disease such as allergic rhinitis

• Systemic disease that places the patient at significant risk from generalanesthesia

Anesthetic Considerations

• General anesthesia with a cuffed oral endotracheal tube stabilized on thechin of the supine patient The anesthetic machine is on the patient’s leftside to permit the surgeon (may be opposite if surgeon left handed) tostand on the patient’s right side

Preparation

• The head is placed on a ring for stability, and a small roll is under theshoulders to achieve a neutral position

• The surgeon wears a headlight to facilitate visualization

• Pledgets soaked in oxymetazoline solution are placed in both sides of thenasal cavity

Procedure

• The membranous septum and the submucoperichondrial layer of theanterior aspect of the quadrilateral cartilage (QC) are infiltrated with 5-10 mL of 1% lidocaine with 1:200,000 epinephrine solution using a25-gauge needle

• Using a No 15 scalpel blade, a right hemi-transfixion incision is used toexpose the caudal end of the QC The incision is made from anterior toposterior to avoid damaging the alar rim (Figure 11–5)

Figure 11–5 Completing the

right hemi-transfixion incision.

• On the concave side of the nasal septum, the mucoperichondrium is sected back 4-5 mm from the edge of the QC using Converse scissors(Figure 11–6) A Beaver blade is used to gently incise the perichondriumlayer; the incision area is “rubbed” with an applicator stick to gain access

dis-to the exact plane beneath the perichondrium for further dissection

• The mucoperichondrium is dissected with a Freer elevator (Figure 11–7)posteriorly and inferiorly until the anterior aspect of the vomer and thejunction with the nasal crest of the maxilla is exposed Dissection is nowcompleted in a more measured fashion as one proceeds past the junction

of the QC with the nasal crest of the maxilla to the floor of the nose

• Using the Freer elevator or a Beaver blade on a long scalpel handle, anincision is made in the inferior aspect of the QC parallel to, but 5-6 mmfrom, the junction of the QC with the nasal crest of the maxilla Thisincision must not extend anteriorly to the anterior nasal spine This strip

of cartilage is mobilized and ideally removed without damaging themucous membrane on the opposite side of the septum (the occurrence

of a linear tear in the mucous membrane on the convex side of the tum is not problematic as this will now serve as the “drainage” site)

sep-• The Freer elevator is inserted from the concave side into the chondrial area on the convex side; the mucous membrane on the convexside is elevated off the QC and the vomer as required, permittingremoval of all areas that are significantly off the midline

subperi-• The QC is not disarticulated from the ethmoid plate; in fact, there is aslittle dissection superiorly as possible To preserve the integrity of thedorsal strut, no cartilage is removed anterior to a line from the anteriornasal spine to the nasal bones

• When excision of cartilage and bone (Figure 11–8) is complete, thehemi-transfixion incision is closed with 3 or 4 interrupted stitches ofabsorbable suture (4-0 chromic catgut)

• The septum is usually quilted using absorbable suture (4-0 plain catgut)mounted on miniature Keith needles:

1 The suture has a needle at each end; one needle is cut off, and a knot

is placed in the suture close to that end

2 The remaining needle is driven back and forth through the septumstarting 2-3 cm from the anterior naris and working anteriorly

3 The “quilting” is continued for about six passes of the needle Thetension on the suture is maintained by placing a knot when the quilt-ing has been completed

• Occasionally, there will be persistent bleeding A small amount of line gauze packing is inserted to achieve hemostasis

Vase-Postoperative Care

• Packing, if used, is removed the next morning

• The patient is seen 1 week later to ensure that a septal hematoma has notoccurred

• The family is cautioned at the time of discharge that normal activity can

be resumed 2 weeks after surgery

268 Surgical Atlas of Pediatric Otolaryngology

EXTERNAL APPROACH FOR SEPTOPLASTY

The external approach for septoplasty allows a wide variety of techniques

to be employed based on the type of septal deformity:

• If the pathology is posterior, excision of cartilage only can be utilized (the

indication for the external approach has been the rhinoplasty part of theprocedure)

• If the pathology is anterior, the posterior aspect of the QC can be used

as a free graft to replace the area that is crucial to the support of the noseand cannot be excised This procedure is described below

• If the case is a revision surgery, only fragments of cartilage may remain

and may need to be filleted and sewn together to make a large enoughfree graft to be reinserted to provide mid-third support

• If the cartilage is missing (the situation after a nasal septal abscess),

endogenous cartilage from the rib (first choice) or auricle can be used tocreate a free graft for insertion

The versatility of this approach is offset by increased morbidity andcomplexity of postoperative care (see below) Late complications, such asstitch granuloma, are more common because a nonabsorbable suture isused to fix the free graft in place Moreover, salvage surgery can be chal-lenging if further trauma to the nose occurs Lastly, the correct insertion of

a septal free graft is a difficult procedure to master if nasal surgery is doneonly occasionally

Indications

• Anterior septal pathology interfering with nasal valve function; thedeformity is caudal to a line from the anterior nasal spine to the nasalbones (Figures 11–9 and 11–10)

• Posterior septal pathology when an external approach is needed for acoexisting problem, such as an asymmetric nasal deformity in a cleft lip

or palate patient

• Revision septoplasty

Contraindications

• Mucosal disease significantly interfering with nasal function

• Systemic disease putting the patient at significant risk from general thesia

anes-• Lack of parental insight as to degree of septal pathology requiring thistype of operative approach

Anesthetic Considerations and Preparation

• General anesthesia is required with a cuffed oral endotracheal tube bilized on the chin of the supine patient

sta-• Pledgets soaked in oxymetazoline solution are placed in both sides of thenasal cavity

• The anesthetic machine is on the patient’s left side to permit the surgeon(if right-handed) to stand on the patient’s right side

• The face is prepped and a towel is wrapped tightly about the head justabove the eyebrows to facilitate holding a miniature Aufricht retractor inplace when the nose has been decorticated A full body drape is applied

• The soft tissues of the nose are injected with 1% lidocaine and1:200,000 epinephrine solution More solution is injected in the mem-branous septum, beneath the anterior aspect of the perichondrium ofthe QC, and in the pyriform aperture area if medial and lateralosteotomies are to be completed Usually, about 10 mL are injected

• The transcolumellar incision is drawn on the skin with a reverse gullwing silhouette to minimize the impact of any scar retraction (Figure11–11) The incision is placed outside of the feet of the medial crura sothat the crura base is undisturbed

• Rim incisions are made with a No 15 blade 1-2 mm inside the nostrilsill, from the apex of the external naris of the nostril to the lateral aspect

of the transcolumellar incision (Figure 11–12)

• Converse scissors are used through the right rim incision to create aplane of dissection outside the medial crura towards the left rim incision(Figure 11–13):

1 The tips of the scissors are pushed through the left rim incision

2 Next, through the right rim incision, dissection is carried up over theleft dome area

3 Then, through the left rim incision, dissection is carried over the rightdome area

4 Lastly, through the right rim incision, the skin is undermined orly beyond the transcolumellar incision

inferi-Figure 11–11 The location and

form of the transcolumellar

incision.

272 Surgical Atlas of Pediatric Otolaryngology

• The transcolumellar incision is completed using a No 11 blade held atright angles to the skin (Figure 11–14) using a sawing motion Only 2

mm of the blade tip are inserted to minimize any damage to the lying medial crura

under-• The rim incisions are then advanced on each side along the caudal der of the lateral crura For this maneuver, it is crucial that an assistantapply counter traction to the dome of the lower lateral cartilage using askin hook (Figure 11–15)

bor-• Once the rim incisions are of adequate length, dissection is carried “overthe domes” until the upper lateral cartilages (ULCs) are encountered Dis-section is then carried superiorly in the midline over the ULCs and nasalbones creating a pocket in which the miniature Aufricht retractor can beinserted The retractor is inserted to hold the skin out of the surgical field,and is stabilized on the towel above the eyebrows with a Kelly clamp

• Next, the operator and assistant each pick up the medial crura with aBrown forceps The operator divides the medial crura with a Beaverblade, cutting through the membranous septum until the caudal end ofthe QC is encountered and delineated down to the level of the anteriornasal spine (Figure 11–16) Gordon hooks are hung on the medial crura

to keep them out of the surgical field

• Converse scissors are used to begin the dissection under the mucousmembrane on the concave side of the nasal septum It is important thatthis initial dissection be 4-5 mm from the attachment of the ULCs tothe QC A Beaver blade is used to gently incise the perichondrium, andthe incision is “rubbed” with an applicator stick so the proper plane isentered with the Freer elevator

Figure 11–14 The No 11 blade

is utilized to complete the

transcolumellar incision.

• Dissection will be limited because of the attachment of the ULCs to the

QC This attachment is divided under direct vision in a progressive ion with a Beaver blade until the nasal bones are encountered Dissectioncan now be carried posteriorly until the vomer is encountered; superior-

fash-ly until the junction of the ethmoid plate and the undersurface of thenasal bones is reached; and inferiorly to the floor of the nose from theanterior nasal spine to beyond the juncture with the vomer bone Ideal-

ly, this is accomplished while keeping the mucous membrane intact

• Returning to the anterior aspect of the QC, a Converse scissors elevatesthe mucous membrane on the convex side of the septum away from theedge of the dorsal strut, again remaining 4-5 mm from the attachment ofthe ULCs with the QC Dissection will be facilitated by the progressiverelease of the ULCs from the QC Care must be taken when goingaround the septal spur towards the nasal floor, because the QC must usu-ally be dislocated from the nasal crest of the maxilla towards the concaveside of the nose to permit adequate access Again, the mucoperichondri-

um is elevated off the entire QC to the undersurface of the nasal bones,onto the perpendicular plate of the ethmoid, and onto the vomer bone

• The connective tissue at the junctions of the QC with nasal crest of themaxilla, the vomer, the perpendicular plate of the ethmoid, and theundersurface of the nasal bones are divided using the Freer elevator Par-ticular attention must be paid to the fibrous bands attaching the QC tothe anterior spine and these may need to be divided with a Beaver blade.The QC can now be removed in its entirety (Figure 11–17) The QC isthen kept moist in sterile saline until remodeling

• Bone off the midline is now removed from the vomer and the nasal crest

of the maxilla, while maintaining the perpendicular plate of the ethmoidintact The upper surface of the anterior spine is trimmed to take off anyirregular spicules of bone, but caution is exercised to not remove any sig-nificant amount of bone in this area

• The inferior fixation suture (4-0 Mersilene) to be used later is placedthrough the anterior nasal spine (Figure 11–18):

1 With a firm, rotatory motion, an 18-gauge needle is driven in themidline from the anterior-inferior face of the anterior nasal spine up

to the superior aspect

2 The needle is used to guide the suture needle through the bone

3 Care is taken to place the first knot (a double throw) on the uppersurface of the anterior nasal spine exactly in the midline

4 Two (single throw) knots secure this suture position This suture isnow put aside for future use

• The distance from the anterior nasal spine to the nasal bones is measuredwith surgical calipers (Figure 11–19) This distance has varied from 19-

33 mm in 85 patients (aged 4 to 16 years) for whom data are available

276 Surgical Atlas of Pediatric Otolaryngology

• The template for the free graft is now made:

1 The QC is placed on a paper drape and the outline of the dorsal strutand the caudal strut is traced past the approximate junction with theanterior nasal spine

2 One end of the surgical calipers (set at the distance determined fromthe anterior nasal spine to the nasal bones) is placed on the approxi-mate position where the QC articulates with anterior nasal spine Theother end then determines where the free graft will meet the nasalbones (Figure 11–20)

3 A notch is drawn into the template (Figure 11–21), as this will be thepart of the free graft that fits under the nasal bones

4 Finally, one end of the calipers is placed on the paper where the nasalbones meet the free graft, and the other end is used to draw an arc inthe template so that the position of the inferior fixation suture can bealtered as required when one completes the sagittal swing maneuver.The template is now cut out of the paper drape

• The QC is now remodeled to create the free graft The QC is examinedand the template is positioned on it to determine the best part to use,ideally the straightest and strongest area (Figure 11–22)

• The anterior pathology is trimmed away, saving the excised cartilage forpossible later use (ie dorsal graft, columellar strut graft, tip graft, etc).With the template as a guide, a No 15 blade is used to carve out the freegraft (Figure 11–23)

Figure 11–20 The distance

determined by the surgical

calipers is transferred to the

paper template.

• The free graft is placed between the mucous membrane flaps with thenotch under the nasal bones Two interrupted sutures of the 4-0 Mersi-lene are placed through the ULCs and the edge of the free graft 1 and 3

mm from the nasal bones (Figure 11–24) The first knot of each suture

is a double throw, as this will maintain tension until the second knot (asingle throw) is placed and tightened

• The skin of the nose is loosely draped in its normal position Throughthe incision, the free graft is grasped in Brown forceps and rotated for-ward in the sagittal plane (the sagittal plane swing maneuver) until thecorrect support of the supratip region is obtained

• The suture inserted earlier at the anterior nasal spine is used to fix thefree graft in place (Figure 11–25) The first knot receives a double throw,and subsequent throws are single When in doubt, fix the free graft toofar in the anterior position as the septal angle area of the free graft canalways be shaved down to the correct level

• Using Keith needles, two transfixion sutures of 2-0 chromic catgut areplaced through the free graft for additional stability (Figure 11–26)

• If the nasal bridge is asymmetric, medial and lateral osteotomies arecompleted at this time For the medial osteotomies, the osteotome isplaced by direct vision so that it engages the nasal bones but misses theupper fixation sutures Medial and lateral osteotomies have been com-pleted in 20% of 169 patients (mean age 12 years, youngest age 6 years)that have had the free graft procedure during the past 14 years

Figure 11–24 The free graft

being sewn to the upper end of

the upper lateral cartilages.

280 Surgical Atlas of Pediatric Otolaryngology

• Other rhinoplasty-type maneuvers (see below) tip grafts, dorsal grafts,ULC augmentation, etc) are completed at this time

• The lower lateral cartilages are sutured back together with interruptedVicryl sutures The skin edges of the columellar incision are gentlyopposed with 5-7 interrupted sutures of 5-0 Prolene; it is important thatthese are not tight so that they can be easily removed The rim incisionsfrom their lateral extent to the midline are closed with interruptedsutures of 4-0 chromic catgut

• A drainage incision approximately 1 cm in length is made in the

inferi-or aspect of the nasal septum, 2-3 cm posteriinferi-or to the anteriinferi-or nasalspine; any accumulated blood is suctioned Two strips of Vaseline gauzeare inserted into each side of the nose, taking care to not pack the nosetightly as pain will result

• An overlying adhesive dressing is now applied A premanufactured splint

is also applied to the nose if medial and lateral osteotomies were done

A “moustache” dressing is used for 2 days to catch any material thatseeps from the nose

Postoperative Care

• The nasal packing is removed early in the morning 2 days followingsurgery, and the patient is discharged from hospital later the same day.The parent is instructed to apply antibiotic ointment to the columellarincision area twice each day until dressing removal

• Nasal packs remain in place for 2 days, during which time the patient ishospitalized Sutures must be removed from the columellar incision aftersurgery, which may very occasionally require a general anesthesia inyoung children Further office visits are needed at 1 and 3 months post-operatively to ensure satisfactory healing

• At the time of discharge, the parents are instructed to call or return tothe hospital if there is any fever, increased facial pain or swelling, orincreased difficulty breathing through the nose All of the latter mayindicate the development of a postoperative infection

• The overlying adhesive dressing and cast are removed 7 to 8 days lowing surgery The patient remains at home until this visit and returns

fol-to school the Monday after this visit Full activities can be resumed 1month after surgery

Special Considerations

• Completing a reduction rhinoplasty at the same time that a free graftprocedure is done is a technically difficult and high-risk procedure.Therefore, the patient and family are warned that a second proceduremay be required at some time in the future if such a goal is appropriate

• Postoperative nasal airflow studies are ideally completed 1 year ing surgery

follow-• Ongoing follow-up with respect to the appearance and subsequent growth

of the nose is very much dependent on the age of the child at the time ofsurgery Patients may be safely discharged from care at age 16 years

Although often carrying a cosmetic connotation, rhinoplasty can also beperformed for reconstructive and functional reasons Open reduction ofnasal fractures, the correction of dorsal septal deformities, and additive orreductive changes to the nasal framework may all be considered forms ofrhinoplasty As noted above, rhinoplasty can be performed at any age ifconservative techniques are utilized Surgery for strictly aesthetic purposes,however, should not be performed prior to age 15 years

Rhinoplasty may be performed via an endonasal approach or a umellar incision (external or open approach), each method offering specif-

transcol-ic advantages and disadvantages (Table 11–1) When functional and metic deformities coexist, techniques that simultaneously address theseptum and external nasal framework may be combined to offer a single-stage return to form and function Finally, because of its central location onthe face, an aesthetically displeasing nose can be the source of much emo-tional and psychological discomfort for the teenage patient

cos-Indications

• Reduction of a complicated nasal fracture (ie, involving both bony andcartilaginous structures or one that occurs in primarily an anterior-pos-terior direction)

• Reduction of a nasal fracture not initially treated or inadequatelyreduced by closed techniques In these cases, rhinoplasty should bedeferred at least 3 months from the time of original injury or failedclosed reduction

• Simultaneous functional and cosmetic repair of a traumatically or

congen-itally deformed nose (see also External Approach for Septoplasty-Indications).

• Alteration of an aesthetically displeasing nose

Table 11–1 Endonasal vs external approach for rhinoplasty

Approach Advantages Disadvantages

Endonasal ✓ Allows better intraoperative × More difficult to judge symmetry

visualization of final result during tip maneuvers

✓ Preferred for simple tip × Cannot address or reconstruct maneuvers or if no tip surgery dorsal septum, if affected

is necessary

✓ No visible scar

External ✓ Allows more precise tip surgery × Potentially visible external scar

✓ Affords excellent access to the × Difficult to judge or visualize dorsal septum, if affected final result

✓ Less destructive to existing nasal × Slightly more time consuming support mechanisms

282 Surgical Atlas of Pediatric Otolaryngology

Anesthetic Considerations

• All pediatric rhinoplasty surgery is performed under general cheal anesthesia to ensure maximal airway control and safety

endotra-• Local anesthesia consisting of 1% lidocaine with 1:100,000 epinephrine

is utilized to ensure a dry operative field and to diminish the ments for general anesthesia

require-• If using general anesthesia with local infiltration, there is no reason touse topical cocaine and this practice has been abandoned

Preparation

• The patient is positioned as for closed reduction

• A lightweight headlight with halogen light source and 2.5x surgicalloupes are used

• Following intubation, a throat pack is fashioned by tying a piece of tiefrom a surgical mask around the sponge portion of a “no detergent”scrub brush The pack is inserted transorally into the oropharynx to pre-vent blood from entering the trachea or esophagus, and to help to avoidpostoperative aspiration or nausea

Procedure

Two approaches are described: endonasal and external

No 1 Endonasal approach for rhinoplasty

• After allowing 10-15 minutes for vasoconstriction, a hemi-transfixionincision is made with a No 11 blade (Figure 11–27) If concomitantseptoplasty is to be performed (see section on septoplasty), it isaddressed at this point of the operation

• A contralateral hemi-transfixion incision is made after septoplasty iscomplete (if performed), and the two incisions are connected with afine blunt scissors The resulting transfixion incision crosses the mid-line, but is not carried all the way down to the anterior nasal spine

• Intercartilaginous incisions are made bilaterally with the No 15 blade,remaining close to the scrolled edge of the upper lateral cartilage (Fig-ure 11–28) A fine blunt scissors is inserted into the intercartilaginousincision and spread three times until a “pop” is felt (fibers connectingthe upper and lower lateral cartilages)

• A slightly heavier scissors (small Metzenbaum) is introduced throughthe incision, and with the contralateral hand pinching up the dorsalskin and musculature, the scissors is opened and closed several times

as it is advanced towards the radix (Figure 11–29) By utilizing thecontralateral hand to pull up the nasal superficial musculoaponeurot-

Correction of dorsal and bony deformities

• An Aufricht retractor is inserted between the nasal bone and cartilage,below, and the skin and muscle, above The dorsal septum is immedi-ately visible from the anterior septal angle back to the rhinion If a car-tilaginous dorsal hump exists, it can now be trimmed with a No 11 or

No 15 blade (Figure 11–30) The trimming should be incremental, stantly monitoring the profile after each sliver of cartilage is removed; it

con-is easier to prevent an over-resected dorsum than to correct one

• Bony humps or spicules can be addressed by inserting a fine diamondrasp over the bony dorsum, and by rasping with a to-and-fro motion(Figure 11–31) This should be performed equally from each side so

as not to create asymmetry When withdrawing the rasp out of thedorsal pocket, first lift the rasp off the nasal bones so as not to “catch”and avulse the adjoining upper lateral cartilages The rasp should berinsed frequently with saline to remove bone dust and other debris

• After checking to make sure that the profile is properly aligned (smallmodifications can, and often should, be left until after the tip work iscompleted), bilateral pyriform incisions are made with the electro-cautery just lateral to the anterior end of the inferior turbinates

• If a sizeable bony hump has been removed, medial osteotomies areseldom necessary If indicated, however, they are performed by insert-ing a curved guarded osteotome up through the nasal mucosa at thejunction of the upper lateral cartilages and nasal bones on either side

of the bony nasal septum A short oblique osteotomy is created byhaving the surgical assistant tap the osteotome with a mallet, whiledirecting the osteotome in the direction of the medial canthus (Fig-ure 11–32)

• Curved guarded osteotomes are then inserted through the pyriformincisions and “locked” into place on the pyriform rim; proper place-ment is confirmed by the ability to rock the head back and forth withthe handle of the osteotome A high-low-high lateral osteotomy isperformed: (1) high up on the pyriform rim, then (2) low down intothe nasomaxillary groove, then (3) high up towards the radix at thelevel of the medial canthus By continually palpating the blunt guard

of the osteotome under the skin, the path of the osteotomy can beprecisely controlled (see Figure 11–32)

• The nasal bones are gently infractured with manual digital pressure

By keeping the majority of the periosteum over the nasal bones intact,there is much less chance of nasal bone collapse following osteotomy

In performing osteotomies earlier, rather than later, in the

rhinoplas-ty, there is generally less bleeding encountered

286 Surgical Atlas of Pediatric Otolaryngology

Correction of nasal tip deformity

• The nasal tip is now addressed and three situations exist that areamenable to simple endonasal tip plasty:

1 If the tip shape is acceptable, but its position in space is deemedundesirable, modifications of the underlying septum (caudally ordorsally) may alter rotation or projection Reduction of the dorsalportion of the caudal septum or the nasal spine area will result intip deprojection A triangle of septal cartilage may be trimmedfrom the most caudal part of the septum (via the transfixion inci-sion) to allow the nasal tip to slightly rotate up

2 If the tip is slightly bulbous, but the domes of the lower lateral

car-tilages are close together, a retrograde cephalic trim may be

per-formed via the intercartilaginous incision with aid of an assistant:

• A fine blunt scissors is used to dissect on both sides of the

lat-eral crus of the lower latlat-eral cartilage (Figure 11–33A) The

car-tilage is thereby freed from the overlying nasal skin and theunderlying vestibular lining

• With an assistant helping to evert the lateral crus, a conservativestrip from the cephalic margin can be directly excised (Figure

11–33B) This should be performed evenly on both sides,

gen-erally removing only 3-4 mm of cartilage

3 If the tip is bulbous and the domes are far apart or asymmetric, thelower lateral cartilages should be delivered prior to modification:

• Bilateral infracartilaginous (marginal) incisions are performedwith a No 15 blade (Figure 11–34) A blunt fine scissors is used

to dissect directly over the top of the lateral crus and exits at theintercartilaginous incision