Fibrin glue.

Editor:

I recently read the article in your March issue entitled, "Fibrin glue prevents complications of septal surgery: Findings in a series of 100 patients" by Payam Daneshrad, MD, Gregory Y. Chin, MD, and Dale H. Rice, MD (Ear Nose Throat J 2003;82:196-7). Although I am sure that the fibrin glue works to approximate flaps, I would like to point out that it appears in the article that the septum is not reconstructed--that is, removed cartilage and bone are not replaced to create a rigid septum. This is akin to malpractice.

For a proper and efficient nasal cycle, the turbinates need a rigid septum to be their reference point. Without that, they simply become hypertrophic and acyclic, and the nasal airway obstructs. Reconstruction of the nasal septum with septal packing or splints is still the logical way to go.

Glenn W. Drumheller, DO

Everett, Washington

The authors respond:

We thank Dr. Drumheller for his comments. First, we would like to point out that our article did not at all comment on the technique of septoplasty except for the final stage--applying the fibrin glue. In point of fact, the fibrin glue works equally well whether or not removed pieces of cartilage and bone are replaced prior to closure.

Although Dr. Drumheller believes that the failure to replace cartilage and bone is "akin to malpractice," this issue is unsettled in our literature even to this day. As Cantrell has pointed out, excised cartilage and bone obstructing the middle meatus in endoscopic sinus surgery need not be replaced. (1) That is the setting under which many of these cases were in fact performed. Furthermore, Guyuron et al have written that submucous resection is the treatment of choice for a deviated septum. (2) Their exhaustive study of the various types of septal deformities and their proposed solutions all involved resecting but not replacing cartilage and bone. In a prospective study of the cosmetic effects of submucous resection, Phillipps found no instance of complications of the ones usually cited for submucous resection. (3) In addition, he found no support in the literature for these side effects. Phillipps surmised that these were probably anecdotal cases in the literature. Finally, Fjermedal et al conducted a 5-yea r comparison of septoplasty and submucous resection and found no differences in complications or in patient satisfaction between the two. (4)

We also read with interest Dr. Drumheller's concern that a "proper and efficient nasal cycle" requires a rigid septum. It has been our experience over time that the scarring produced in either operation is generally sufficient to make a fairly rigid septum. More important, however, is the fact that the presence of the nasal cycle is not uniform in the human population. In a study of the influence of age on nasal cycles, Mirza et al found that the nasal cycle was present in fewer than 25% of the patients they studied. (5) Also, in an intriguing study measuring the spontaneous changes in unilateral nasal airflow, Flanagan and Eccles found the nasal cycle to be present in 21% of their studied subjects. (6) Interestingly, we know of no scientific study in the literature that shows the impact of septoplasty in its many guises as having any impact on nasal cycle.

We have no objection to those who continue to be more comfortable with packing or splints, but we do feel that fibrin glue is a viable alternative.

Dale H. Rice, MD

Payam Daneshrad, MD

Gregory Y. Chin, MD

References

(1.) Cantrell H. Limited septoplasty for endoscopic sinus surgery. Otolaryngol Head Neck Surg 1997;116:274-7.

(2.) Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast Reconstr Surg 1999;104:2202-9; discussion 2210-12.

(3.) Phillipps JJ. The cosmetic effects of submucous resection. Clin Otolaryngol 1991;16:179-81.

(4.) Fjermedal O. Saunte C, Pedersen S. Septoplasty and/or submucous resection. J Laryngol Otol 1988;102:796-8.

(5.) Mirza N, Kroger H, Doty RL. Influence of age on the "nasal cycle." Laryngoscope 1997;107:62-6.

(6.) Flanagan P, Eccles R. Spontaneous changes of unilateral nasal airflow in man. A re-examination of the "nasal cycle." Acta Otolaryngol 1997;117:590-5.