;

Septoplasty; Current Concept and Technique

,

,
.

,
.

. (basic septoplasty)
(extracorporeal septoplasty), (laser-assisted
septoplasty), (endoscopic septoplasty), (sagittal
section septoplasty) .

,
.

(columella) (nasal tip)
.
,
.
, (perpendicular plate of ethmoid), (vomer),
.
( (quadangular cartilage)) 3-4 mm
4-8 mm (premaxillary
wing) (processus lateralis ventralis) .
(upper lateral cartilage) (nasal septal angle) .
.
(sphenoidal process) .
,
(nasal spine), (cribriform plate) ,

 , , .
, (maxillary
crest) (palatine crest) , ,
(sphenoidal crest) .
(choana) .
8 , (anterior nasal spine),
, , , , , ,
( 1).

1. .

(mucoperichondrium)
( 2).

2. .

(anterior nasal spine)

.
,

 ( 3).

3.
.

(nasal
valve) (limen nasi) . (nasal valve area)
, (premaxillary wing)
(internal ostium) (isthmus) .
(nasal valve angle) ( 4).

4. (nasal valve area). (internal ostium)

(isthmus) . 1: (nasal valve angle), 2: ,
3: (premaxillary wing), 4: ((limen nasi)
), 5: , 6: , 7: .

 2-9 mm (vomeronasal organ of

Jacobson) . (septal
tubercle)
Little Kiesselbach .

1.
1958 Cottle ,
(subluxation), (large spurs), (caudal deflection),
(tension septum) 4 .
(spine, spur), (crest, ridge),
.

(basal crest) .
,
.
,
( )
.
.
C , S , ,
, .

2. Mladina
Mladina 7 (Mladina, 1987). 14 (craniocaudal) , 5-6 (anteroposterior)
, 7 1-6 ( 5).
1 : (nasal valve) , (nasal
dorsum) .
2 : ,
.
3 : .
4 :
, 2 3 .
5 : .
6 : (gutter)
.

7 : 1-6 .

5. Mladina . 1-4 (craniocaudal)

, 5-6 (anteroposterior) ,
7 1-6 .

3 , 5 , 6 , 1 , 2 , 4 , 7
.
2 1 (Min et al.,
1995).

3. Guyuron
1999 Guyuron 6

( 6). 93 Type I 40%

septal tilt

. Type II 32% C
. Type III(4%) C
(cephalocaudal) . Type IV
S (9%), Type V S . Type VI
spur 14% .

 6. Guyuron

4. Sciuto
Sciuto (1999) 1982 Gomulinski
(bending axis) ,
( 1, 7).

1. Classification of nasal septal deformities by Scuitto (1999)

a horizontal : horizontal angulation or bending of the quadrangular cartilage
b vertical vertical angulation or bending of the quadrangular cartilage
b1: caudal-vertical angulation of bending axis directed towards a dorsal point
distal from the upper lateral cartilage insertion
b2: mid-vertical angulation of bending axis directed towards a dorsal point
below the ULC insertion
b3: high-verical angulation of bending axis directed towards a dorsal point
corresponding to the bony vault
c combined multiple angulations or bending including traits of both a and b.

 7. Sciuto

5.
Buyukertan(2003) CT
, ,
10
2
.

6.

( 2).
.

2.
Type
Type
Type
Type

I : Localized deviation including spur (spine), crest, caudal dislocation

II : Curved/angulated deviation without localized deviation
III: Curved/angulated deviation with localized deviation
IV: Curved/angulated deviation with associated external nasal deviation

(nasal obstruction)

(, paradoxical nasal obstruction),

(nasal cycle)
.

( 3).

 3.

(Divergent medial crural footplates)
(Wide columella)


(Alar sidewall flaccidity)
(Dependent tip of aging)

(postnasal drip), (mouth breathing)

,
. (head dullness), , ,
, (rhinolalia clausa), .
,
, (anterior ethmoidal
nerve syndrome) . , ,
, (concha bullosa)
(Anselmo-Lima et al., 1997).

, Sluder
(Sluder,

1913).

(nasopulmonary

reflex)

(Ogura et al., 1971).

,

.
(turbulant flow)
. ,
Kiesselbach .
(metaplasia)
(ostiomeatal unit)
(Collet et al., 2001).

(compensatory hypertrophy)
.
. Kiesselbach
(scoliotic nose)
.
(concave side) (convex side)


(glandular acini) (Jang et al., 2002).

1.
(anterior rhinoscope)
.

,
Cottle ( 8).
.
(spreader graft)
.

8. Cottle .
.

2. (rhinomanometry)

( 9).
.
, ,
,
. .

 9. (rhinomanometry). (P) (FL)

, (R, L) (IN) (EX)
.
.

3. (acoustic rhinometry)

(Grymer et al., 1989).

. W 1
I notch, 2 C notch
( 10).
, , , .

10. (acoustic rhinometry).


1.
,
.
,

, .
,
.
.
, , ,

2.
19 ,

.

(Rubretch, 1868).

(Asch, 1899).

1898

Jacques Joseph
( 11).

 11. Joseph .

.
1882 Ingals , 1902
Freer

, (saddle nose),
Killian (1904)
( L

strut)

(submucous

resection)

. 20
.

, ,
.
.

(exenteration) .

(septoplasty) . ,
, , swinging door , spreader graft
(cartilage splinting)
.

3.
1947 Cottle Loring -(maxilla premaxilla)

Cottle-tunnels ,

1950

Converse (crosshatching incision) , 1969 Rubin

(morselize) (interlocking stress force)

(morselization) .

.
(chondrocyte)
interlocked stress (Gibson and
Davis, 1958).
.
(tensile

force)

(compressive

force)

(Kenedi, 1963)
.
, (Fry, 1966) (
12).

12. .

, (Homicz et al., 2003)
. Murakami (1982) (full
thickness incision) (wedge resection) ( 13)
,
.

 13. (wedge
resection) .

ten Koppel
(2003)
10

( 14).

14. .
. Dr = / .

(wedge resection)

.
.
, .
L-strut

1.
,
. ,
.
4% cocaine 4% lidocaine 1:1,000 epinephrine
1% lidocaine 1:100,000 epinephrine
. 1.5 mL , 1.5 mL
( 15).
(hydraulic dissection)
. (pyriform aperture) 2 mL ,
2 mL
.
10 .

15. .

2.
1) 1-2 mm (hemitransfixion incision)
. Killian
modified Killian .

,

 .
2) .
.
Cottle elevator Freer elevator .
Iris scissors .

.

, , .

.
.
(mucoperiosteum) . (nasal
roof), (sphenoid rostrum), (maxillary crest) .

(anterior

tunnel),

(superior tunnel) .
3)
(inferior tunnel) .
. nasopalatine nerve
, .

.

(elevator)
.
4) .

(joint-like capsule)
.
suction tip
.
5)
.

.

3.
1)

.
.
, key stone
1 cm .

.
2) , (
16).

16. . (anterior tunnel, A)

(inferior tunnel, B) ,
(C) (D) .

4.
1) (bone scissors), (osteotome), JansenMiddleton (septum cutting forceps)
.

. (chisel), (gouge),
.
2)

(key stone area), ,

.
. ,
.
3)
(excess cartilage)

 2-4 mm .


.
(
17).
.

17. . key stone

.

4) L-strut ,
(full-thickness
incision) ( 18). .

.

.

 18. (full thickness vertical

chondrotomy)

5) L-strut

1-1.5

cm

.
6)
8 , .
.
. 1-3
(transfixion suture)
, .
silastic sheet
, . 1
.

5.
1)
.
2) cross hatching
.
,
.
3) , ,
.
.
4)
.

6.
1) Silastic sheet : silastic sheet ,

crusting .
.
2) vs. (nasal packing vs. quilting suture):

4-0 5-0 catgut (absorbable suture)
5-7 .
,

.
Yildirim(2005) (nasopulmonary
reflex)
.
3) : (concave side)

.
.
, , , .
, 15
Cottle
. ,
,
. ,
angled turbinate scissors ,
. Turbinate scissors 1/3-2/3 .
,
1-2cm ,
.
.

6.
, ,
- , ( (ventral)
)
30-40% . (convexity or angulation), (dorsal)
( high deviation), ,

 .
,

. splinting
graft high deviation

spreader

graft

1. Swinging door technique
1929 Metzenbaum 1957 Goldman

swinging door

( 19 ).

19. swinging door

2.
,

.

high

septal

deviation

. Spreader graft batten graft

L-strut ,
.

3. (extracorporeal septoplasty)


.

,
, . 1952 King
Ashley ()
.

20).

(external

septoplasty)

(total septal reconstruction)

,
.

, .
.
, , , ,

(contouring)(Gubisch

et

al.,

1999).

L-strut ,
, ,

.
, .

 20. (extracorporeal septoplasty).

.

4. Sagittal section septoplasty

,
,
Godfrey

(1994)

(sagittal

section

septoplasty)

(concave side)
(sagittal plane) ,
, (mattress
suture) .
( 21).

21. (sagittal section septoplasty) .

( 22),
, , .

 22. (sagittal section

septoplasty) .

5. Laser assisted septoplasty

Kamami (2000) CO2 ,
703 90.8%
. , ,
84.5%, 89.9%, 87.2% .
150 sec
.

.
( 23),

.

 23. . CO2
, .

6. (Endoscopic septoplasty)

.

(Stammberger et al., 1993).
4 ,
,
(Dolan, 2004). (bony spur)
( 24) (Raynor, 2005)

4. .
Advantages
Facilitates teaching
No need to change instrumentation during functional endoscopic sinus surgery
Improved diagnosis in the nasal valve area and posterior nasal cavity and septum
Smaller, more targeted, incisions with minimal mucosal dissection
Precise removal of deviated cartilage
Disadvantages
More time-intensive approach
Additional equipment needed
Difficult to reach caudal-most septum
Learning curve

 24. .

7.

Bejar

(1996)

(external septoplasty) 6-15

3.4
.
17 .
,

. (limited resection) ,
.

(convex side)
(concave side) . Pirila (2001)
117 1 ,
.

(cross-sectional

area)

(first minimum cross-sectional area, MCA1) .

.

.

.
,

.
,
.
3 (Ginzel, 1980).


.

1.
(septal hematoma) .

. 3 .

.
.

.
.
, (drain) .
.
.

2.

, .

3. ,
.
, . (nasal vestibulitis)
.
(septal abscess)
.
.

4.
.


.
. (synechiolysis) silastic
.

5.
(septal

perforation)

,

.

6.

(pseudohump)
.
, .

7.
,
, , (Taasan et al., 1981; Buckley
et al., 1991; Jensen et al., 1991).
.

silastic

(toxic shock syndrome), .

,
.

,
.

.


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