BONE SPUR DRILLING , A NEW TECHNIQUE TO CORRECT DEVIATED MAXILLARY CREST

The nasal septum consists of both bony and cartilaginous components which could be deviated resulting in different types of deformities that lead to unilateral or bilateral nasal obstruction in addition to dryness, crustation, and bleeding from the nose. Headache and facial pain may be other presenting features and sinusitis is a possible complication. ENT surgeons tried different surgical techniques to correct these types of septal deviations to ensure the best results and least complications. Forty eight patients (32 males and 16 females) were admitted to Al-Sadr Teaching Hospital with septal deviation in the form of bony spur alone or associated with other nasal septal deflections. Correction of the deviated crest was performed following good exposure by elevating mucoperichondrial flap, and using high speed drill with cutting bur to remove the deviated part or fracturing and repositioning. Patients were monitored for intraoperative bleeding and followed for at least four weeks regarding the development of upper incisors numbness. The results of this study showed that bleeding was much reduced during surgery and only one patient (2.1%) developed upper incisors anesthesia who have sever maxillary crest deviation that necessitated total excision of the spur. This study gives another option for bony spur correction by providing more controlled excision with less intraoperative hemorrhage and postoperative numbness, this improves patients health and relieves discomfort after surgery.


Introduction
he nasal septum lies in the central part of the nose or slightly deviated to one or both nasal cavities 1 .Its deviation can be developmental or traumatic.The anterior septal deviations are more likely to be environmental caused by injuries of the nose or the central part of the face while posterior septal deflections are mainly inherited 2 .Takashi explained that humans are the only species in which septal deflections occur 3 .There are six different types of septal deviations that require different surgical techniques to correct: Septal tilt deviation (the septum not curved but tilted to one side of the nasal cavity anteriorly and to the other side posteriorly), C-shaped anterposterior deviation, C-shaped cephalocaudal deflection, S-shaped anterposterior deviation, S-shaped cephalocaudal deviation, and Localized deviation or large spur (Figure 1).This classification is based on shape of deviation, affected part of the septum and location of deflection such as cephalic or caudal 4,5

Fig. 1: Deviated maxillary crest to the left nasal cavity
Because septoplasty is one of the common surgical procedures in ENT 6 and there are different types of septal deformities so there are many thoughts and trials among ENT surgeons to improve their techniques to get the best results and to save time with less complications.Bony septal spurs removal by the classical technique (osteotomy using gauge and mallet) can be associated with excessive bleeding especially after chiseling large spur in addition to the development of numbness in the maxillary incisors teeth due to injury of the nasaopalatine nerve and also avoiding troublesome bleeding from the nasopalatine artery injury 7 , for these reasons this study aimed to do bony spur drilling technique to minimize or avoid these complications ( Figure 2).

Patients and methods
This study was conducted at Al-Sadr Teaching Hospital, Basrah, Iraq from July, 2015 to July, 2017.The study included 48 cases (32 males and 16 females ) with deviated nasal septum in the form of septal spur with or without other types of septal deformities.
Admitted patients were between the age of 18 to 50 years.
Preoperative evaluation was performed for all the patients including; history, clinical examination using headlight and nasal speculum and/or nasal endoscope, radiological investigations such as X-ray CT-scan of the nose and paranasal sinuses, and laboratory investigations including bleeding profile.
All patients were operated upon under general anesthesia after informed consent regarding the complications of surgery or the possible risk of general anesthesia.Surgical procedure: Both endonasal and open rhinoplasty approaches were used according to the type of septal deviation whether bony spur alone or associated with other types of septal deflections.Mucoperichondrial flap elevation was done through anterior and inferior tunnels or as a part of septorhinoplasty.Careful exploration of the bony spur after uniting the two tunnels was performed.A high speed drill (size of the cutting bur 4.5mm) that is usually used in mastoid surgery was applied to excise only the deviated part of the bony crest instead of using chisel.Severely deviated crests are drilled, fractured and repositioned in the central part of the nasal floor (Figures 3  & 4).All patients were followed up in the outpatient department for at least 4 weeks and the result was assessed by asking the patients about the presence of numbness in the maxillary incisors, while any abnormal bleeding was assessed during surgery.

Results
Forty eight cases were selected to remove maxillary crest spur.They were 32 males (66.7%) and 16 females (33.3%) as shown in table I.

Fig. 2 :
Fig. 2: The nasopalatine nerve and nasopalatine artery running close to the bony septum and passing through the incisive canal.

Table III : Incidence of troublesome bleeding & numbness in this study Type of problem No. of patients Percent
upper incisors following the uncontrolled classical osteotomy of the deviated crest using gauge and mallet.With the use of high speed drill and good exposure of the operative field, the intra operative hemorrhage is much reduced and almost all patients except one (2.1%) got temporary numbness in the upper incisors.This study recommend the use of drilling technique as it is much easier, time saving and gives much controlled excision of only the deviated part of the bony crest and leaving good bony base for septal cartilage to sit on.