Reconstructive surgery septoplasty Article Last Updated: Mar 31, 2006 author and editor information




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Septoplasty

Article Last Updated: Mar 31, 2006

AUTHOR AND EDITOR INFORMATION

Section 1 of 12  




Author: Deborah Watson, MD, Associate Professor, Department of Surgery, Division of Head and Neck Surgery, University of California at San Diego School of Medicine

Deborah Watson is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Phi Beta Kappa, and Sigma Xi

Coauthor(s): Alexander Rivkin, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, University of California at San Diego Medical Center

Editors: Gregory Branham, MD, Vice-Chair, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Saint Louis University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine



Author and Editor Disclosure

Synonyms and related keywords: septoplasty, submucous resection, septal repair, septal surgery, nose surgery, nose job, nose repair, nasal obstruction, septal deviation, nasal septal deviation, epistaxis, sinus ostium obstruction

INTRODUCTION

Section 2 of 12  


  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Nasal obstruction is one of the most common problems bringing a patient into a physician's office, and septal deviation is a frequent structural etiology. As a result, surgical correction of septal deviation is the third most common head and neck procedure in the United States, and it generally is performed to improve quality of life. Presently, a variety of additional indications exists for septoplasty, from intractable epistaxis to harvesting cartilage for use in rhinoplasty (see Indications).

History of the Procedure

3500 BC: The Ebers Papyrus, which contains the first known mention of rhinologic surgery, was written around this time in Egypt. Most of the procedures depicted in it were reconstructive because rhinectomy was a frequent form of punishment.

1757: Quelmatz was one of the earliest physicians to address septal deformities. His recommendation included daily digital pressure on the septum.

1875: Adams recommended fracturing and splinting of the septum.

Late 19th century: The most common operation in the United States was the Bosworth operation to correct nasal obstruction from nasal septal deviation. Using a specialized saw, the deviation was removed along with the corresponding mucosa. Results were suboptimal.

1882: Ingals introduced en bloc resection of small sections of septal cartilage. Because of this innovation, he is credited as the father of modern septal surgery. Around the same time, cocaine was becoming widely used in surgery. With its advent, anesthesia and hemostasis for nasal surgery improved significantly. Longer and more technically refined operations became feasible.

1899: Asch was the first to suggest altering the tensile curve of septal cartilage instead of resecting it. He proposed the use of full-thickness cruciate incisions.

1902 and 1904: Freer and Killian described the submucous resection (SMR) operation. This procedure is the foundation of modern septoplasty techniques. They advocated raising mucoperichondrial flaps and resecting the cartilaginous and bony septum (including the vomer and perpendicular plate of the ethmoid), leaving 1 cm dorsally and 1 cm caudally to maintain support.

1929: Metzenbaum and Peer were the first to manipulate the caudal septum, using a variety of techniques. The classic SMR was less effective in correcting this area of deviation. In addition, Metzenbaum advocated the use of the swinging door technique, and in 1937, Peer recommended removing the caudal septum, straightening it, and then replacing it in the midline position.

1947: Cottle introduced the hemitransfixion incision and the practice of conservative septal resections. Long-term follow-up studies of patients who had undergone SMR occasionally revealed dorsal saddling, retraction of the columnella, and alar widening; therefore, conservative resections during septoplasty were designed to avoid these complications.

Problem



Septoplasty versus submucous resection

SMR is an extensive resection of cartilage and bone, including part of the vomer and part of the perpendicular plate of the ethmoid. A 1-cm caudal and dorsal strut is typically left to support the lower two thirds of the nose.

Conversely, septoplasty is a tissue-sparing procedure. In most situations, the area of deviation is corrected or resected in order to leave behind as much cartilage and bone as possible. Cartilage resection is minimized, particularly when the deviation is located in a structurally vulnerable area (eg, caudal and dorsal regions). In such cases, the cartilage can be repositioned, reshaped, or recontoured using a variety of methods.

Frequency

Nasal obstruction is a common complaint. In 1974, Vainio-Mattila found a 33% incidence of nasal airway obstruction among randomly chosen adults. Septal deviation was found to be the most frequently encountered structural malformation causing nasal obstruction. Clinically significant septal deviation was found in 26% of patients with nasal obstruction in this study.

Etiology

Developmental septal deviation may occur. Patients in whom the septal cartilage has been damaged in the neonatal period and during birth can present with severe septal deviation in the absence of a history of nasal trauma. Microfractures sustained during late intrauterine life and during birth may cause weakness in the damaged side of the cartilage. The result is asymmetric bending of the cartilage toward the side of the injury, while the contralateral side achieves dominance over time. These conclusions are supported by evidence matching the direction of septal deviation with the presentation of the fetal head in the pelvis during delivery.

Septal deviation from traumatic impact can occur in childhood or adult life. Childhood trauma can cause severe nasal obstructive problems in adult life because any degree of septal deviation usually becomes more pronounced with time.

Depending on the direction and force of the nasal injury, septal cartilage can fracture horizontally or vertically, with single or multiple fracture lines, and can be accompanied by damage to the nasal bones or to the perpendicular plate of the ethmoid. In addition, the cartilaginous septum can subluxate from the vomeral sulcus. Usually, the junction of the bony and cartilaginous septum is the area of greatest deviation due to trauma.

Pathophysiology

Septal cartilage provides structural support for the nasal dorsum while maintaining a remarkable degree of elasticity. It can absorb large amounts of force without permanent deformity. When the amount of force applied to the cartilage exceeds its biomechanical stress point, the cartilage fractures.

In the absence of trauma, septal cartilage is usually straight. Each side of the cartilage has an internal tension that is evenly balanced. Traumatic injury usually causes asymmetric damage to the cartilage, resulting in the dominance of one side over the other. Over time, the dominant side of the septal cartilage exhibits marked overgrowth relative to the contralateral side. A deviation results, with the convex side exhibiting the dominant growth pattern. This is often the side ipsilateral to the injury.

The magnitude of injury required to generate a significant septal deviation is inversely proportional to the patient's age. In childhood, particularly during the adolescent growth years, even insignificant trauma to the nose can produce unilateral microfractures that have severe impact upon the growth pattern of the patient's septal cartilage.

Clinical

Patients may present with a history of sinusitis, allergic rhinitis, obstructive sleep apnea, previous nasal surgery, or recent nasal trauma. They often relay symptoms of unilateral or bilateral nasal airway obstruction that is unrelieved with decongestants or nasal steroid sprays. On initial examination, external dorsal deviation may be evident, or the columella and caudal septum may be deflected off the midline.

History


  • A history of prior nasal surgery should raise suspicion of mucoperichondrial scarring and previously resected septal cartilage. Ascertain a history of allergic rhinitis, cocaine abuse, and rhinitis medicamentosa caused by long-term use of decongestant spray.

  • Medications (eg, estrogen, sympatholytics, beta-blockers) can cause nasal congestion. Environmental irritants and certain food allergies (eg, red wine, milk, beer) are also potential culprits.

Physical examination

  • Inspect the nasal cavity before and after nasal decongestion.

  • Anterior and posterior rhinoscopy is helpful in diagnosing the location, type, and severity of septal deformity. Prior to the examination, decongest the nasal cavity with a vasoconstricting nasal spray and anesthetize with a 4% lidocaine nasal spray (or equivalent). Some physicians insert 4% cocaine-soaked cotton pledgets into the nasal cavity to achieve the decongestive and anesthetic effects.

  • Both the anterior and posterior septum should be evaluated. A zero-degree, 3-mm diameter rhinoscope may facilitate inspection of the posterior septum. The endoscope is also useful in identifying polyps, assessing the severity and extent of posterior septal deviations and bony spurs, and locating areas of septal perforation or mucosal injury.

  • The size of the inferior turbinate should be noted during the inspection of the nasal mucosa both before and after the decongestant spray.

  • Allergic rhinitis can present with pale, boggy mucosa with watery discharge. Vasomotor rhinitis, rhinitis medicamentosa, or cocaine abuse usually presents with thickened hyperemic mucosa.

  • A narrow internal nasal valve can be assessed by lateralizing the nasal side wall with a nasal speculum or lateral digital pressure on the patient's cheek. Note any improvement with nasal breathing with these maneuvers.


INDICATIONS

Section 3 of 12  


  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Nasal obstruction

Consider elective septoplasty for patients who have a visible septal deformity but no other identifiable causes for their nasal obstruction (eg, polyps, allergies, turbinate hypertrophy, chronic lung disease) and in whom conservative management (eg, nasal steroid spray) has failed.



Epistaxis

When access to a posterior bleeding vessel is hampered by a severe deviation, perform a septoplasty first to gain posterior access for vessel cauterization or packing.

When normal laminar airflow becomes turbulent secondary to a septal deviation, mucosal drying and crusting become more prevalent and can lead to intermittent epistaxis. Correction of the deviation can ameliorate this problem.

Sinus ostium obstruction

Septoplasty is sometimes necessary to correct a septal deviation that blocks the osteomeatal complex. An endoscopic sinus surgical procedure may follow.



Trauma

Telescoping tearing and dislocation of the septum is a frequent occurrence in closed nasal injuries. Dislocations most frequently occur at the junction between the quadrangular cartilage and the perpendicular plate of the ethmoid bone. Failure to address a malpositioned septum in nasal fracture reduction may lead to eventual nasal obstruction.



Cosmetic

The changes to the nasal structure that are a part of rhinoplasty can cause nasal obstruction in some patients unless the septum is straightened during the procedure. Additionally, the septum is an excellent source of donor cartilage for structural grafting in rhinoplasty.



Surgical access

Pituitary tumor resection is possible through the transseptal-transphenoidal approach.




RELEVANT ANATOMY

Section 4 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Function of the septum

The septum provides dorsal support and helpt to maintain the position of the columnella and nasal tip. It also separates the nasal passages and serves as shock absorption for the floor of the frontal fossa.



Internal nasal valve

The internal nasal valve is located at the caudal edge of the upper lateral cartilage. At this location, the upper lateral cartilage forms an ideal angle of 10-15° with the septum (see Image 1). The cross-sectional area of the nasal cavity is narrowest at the nasal valve, which acts as a funnel to focus and direct air currents and thereby produces laminar flow. Untreated deformities or poor alterations to the area of the valve can cause the valve to collapse or lose its ability to direct the air stream. When airflow dynamics change, subjective sensation of air passage is reduced, and this tends to be perceived by patients as nasal airway obstruction. The subjective sensation of airflow has not been clearly elucidated, but receptors that are sensitive to changes in the laminar airflow pattern and airspeed are believed to be present at the valve.



Blood supply

Blood supply is illustrated in Image 2. The vasculature of the septum runs between the perichondrium and the mucosa. This subperichondrial space is the recommended avascular dissection plane when raising the mucoperichondrial flap during the first step in septoplasty.

Superior blood supply is derived from the anterior and posterior ethmoid arteries, while posterior blood supply is derived from the sphenopalatine artery and the greater palatine artery. The septal branch of the superior labial artery supplies the caudal septum and columnella, and the inferior blood supply is derived from the palatine artery.

Generally, the venous drainage pattern follows the arterial supply, except for a posterior communication with the cavernous sinus.



Innervation

Innervation is supplied by the anterior ethmoid nerve, nasopalatine branch, and the terminal branch of the anterior superior alveolar nerve.




CONTRAINDICATIONS

Section 5 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Medical problems or history that present a contraindication to performing septoplasty include the following:

  • Large septal perforation

  • Cocaine abuse

  • Wegener granulomatosis

  • Malignant lymphomas or monoclonal T- or B-cell proliferations


WORKUP

Section 6 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References



Imaging Studies

  • A CT scan usually is obtained for concurrent reasons, such as assessing sinus disease or evaluating head and/or facial trauma. A deviated septum is readily apparent on a CT film (see Image 3). While septal deviations are apparent on CT scans, obtaining a CT scan is not necessary in a patient in whom no other pathology is suspected (eg, concomitant sinus disease).

  • Plain films are not indicated in most instances; they do not help because the cartilaginous portion of a deviated septum is not easily visible. Direct examination always is best.

Other Tests

  • Many proposed methods of nasal airway analysis exist, including rhinomanometry, acoustic rhinometry, and nasal peak flow. The measurements derived from these methods are not always reproducible and do not consistently correlate with a patient's subjective complaint of nasal obstruction. In general, these types of studies are useful for research in nasal obstruction but provide little clinical value in the decision-making process regarding surgery or medical management.


TREATMENT

Section 7 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References



Medical therapy

Nasal airway breathing can be improved in the setting of allergic rhinitis and congested nasal mucosa by using intranasal phenylephrine (Neo-Synephrine) for several days, followed by a longer-term use of a steroid nose spray.

Patients who have epistaxis initially should be treated with nasal packing or conservative cautery of an identifiable bleeding focus.

Surgical therapy

With a history of recent nasal trauma ( <7-10 d), the nasal bones and deviated septum may be reduced by lifting and realigning the structures with the patient under local and topical anesthesia. If the deviated septum cannot be corrected in this manner or if the septal deformity is long-standing, a formal septoplasty is recommended.

Septoplasty can be performed with the patient under local or general anesthesia. If an adjunctive sinonasal procedure (such as endoscopic sinus surgery or rhinoplasty) is to be performed, it takes place after the septoplasty is completed.

Preoperative details

Inform patients undergoing septoplasty of the risks and benefits of the procedure and of medical therapy alternatives. Risks entail postoperative epistaxis, septal hematoma, sinus infection, unimproved or worsened nasal airway breathing, nasal crusting, septal perforation, saddle-nose deformity, toxic shock syndrome (TSS), cerebrospinal fluid (CSF) leak, and a need for a revision procedure.

Many medications, herbal extracts, and vitamins can prolong a patient's bleeding time, prevent platelet adhesion, and delay coagulation. Patients need to be informed which medications have these effects and refrain from taking them the appropriate number of days before surgery.

Intraoperative details

Intraoperative details include preoperative injections, technique via endonasal and external nasal approaches, elevation of the mucoperichondrial and contralateral mucoperichondrial flaps, correction of deviation, and closure.

Preoperative Injection

Prior to injection, the nose should be packed loosely with cocaine-soaked pledgets to maximize the decongestive effect. Using bayonet forceps, place one pledget along the roof and one along the floor of the nasal cavity.

Maximum dose for cocaine is 2-3 mg/kg. A single 5-cc vial of 4% cocaine typically is used to soak all 4 pledgets for an adult patient.

Inject approximately 5 cc of 1% lidocaine with 1:100,000 parts epinephrine into the subperichondrial and subperiosteal planes throughout the septum to look for blanching of the mucosa, which indicates that the proper plane has been entered. Injections are performed with a long 25- or 27-gauge needle.

Maximum dose of lidocaine with epinephrine is 7 mg/kg.

Techniques via Endonasal Approach

Hemitransfixion incision (see Image 4): This is a frequently used incision, extending from the dorsalmost to the caudalmost point of the caudal cartilaginous septum where it abuts the membranous septum. This incision provides access to both anterior and posterior deviations. Some advocate placing the incision on the side of the deviation, while others prefer to always make the incision on the same side. Making the incision on the left side tends to be most beneficial for the right-handed surgeon.

Killian incision (see Image 4): This incision is placed more posteriorly. If the anterior septum is straight, this is a preferable incision.

Elevation of the mucoperichondrial flap

Meticulousness in finding the avascular subperichondrial plane is important.

Use a Cottle elevator (see Image 5) once the proper plane has been accessed. Dissection should extend beyond the bony-cartilaginous junction of the septum.

Be careful to avoid perforating the mucoperichondrium. However, unilateral perforations are common and usually heal spontaneously. Even bilateral perforations heal well if small and asymmetrically located. Larger, bilateral, and opposing perforations require closure with a rotational mucosal flap.

Take special care when raising the flap at the floor of the nose where the maxillary crest meets the cartilaginous septum. At this point, the mucoperiosteum is attached to the bony crest with fibrous bands. These bands should be dissected sharply.

Elevation of the mucoperichondrial flap around spurs and sharp septal deviations can be difficult. These areas usually have more tenacious attachments to the mucoperichondrium or periosteum, secondary to thinning and scarring of the tissue after a traumatic deviation or during growth of the cartilage.



Elevation of the contralateral mucoperichondrial flap

In order to inspect the bony ethmoid plate, a transcartilaginous incision should be performed at the junction of the cartilage with the ethmoid plate (see Image 6A). The incision should be extended down to the maxillary spine at the caudal area. Dorsally, the incision should leave at least 1 cm of cartilage undisturbed. Through this approach one can elevate the contralateral periosteum.

In 1993, Sessions and Troost recommended excising a boomerang shape of cartilage from the cephalodorsal-most point of the cartilage to the ventral-caudal–most point on the maxillary spine. This creates a swinging door effect (see Image 6B)

Gain access to the contralateral mucoperichondrium by removing a strip of cartilage along the inferior border adjacent to the maxillary crest (see Image 6C).



Techniques via an External Nasal Approach

After the skin/soft tissue envelope is elevated from the nasal tip cartilage, a sharp midline dissection is performed while gently retracting the lower lateral cartilages laterally. Once the anterior septal angle is identified, following the nasal septum and elevating the mucosal flaps bilaterally in the correct plane become easy (see Image 7).



This approach provides a generous view of the septum and is an ideal approach for septal perforation repair.

Correction of the Deviation

  • Resection of cartilage and bone

    • Preserve a 1-cm (or greater) L-strut on the caudal and dorsal aspects.

    • Use an osteotome or rongeur for bony resection along the maxillary crest.

    • Avoid pulling on attached tissue when removing cartilage or bone. Use Takahashi forceps to remove tissue safely. When the forceps have engaged the tissue completely, twist the tissue free prior to removing it from the nasal cavity. Pulling on tissue that is not completely severed from the surrounding structures may increase the risk of damage to the cribriform plate, since a large portion of septal tissue is connected to the ethmoid structures.

    • After correction of bony deviations, replace the cartilaginous septum on the trough of the maxillary crest. If it can be aligned without a deviation intruding into either nasal airway, consider ending the operation with closure of the mucoperichondrium and placement of quilting suture or stents. Sometimes, an anchoring suture, passed through the posterior septal angle and nasal spine, is necessary for stabilization of the cartilaginous septum.

    • If the cartilage is deviated in an area outside the support structure of the L-strut, it can be resected in small pieces, preserving as much in place as possible.

    • Cartilaginous incisions can be made with a D-knife, a Cottle knife, or a No 15 blade scalpel.

    • Cartilage can be removed, straightened manually by morselizing or scoring the surface of the cartilage, and replaced between the septal flaps.

  • Cartilaginous incisions or scoring of cartilage

    • This technique weakens the tensile strength of the cartilage and, after postoperative splinting, encourages it to scar into a straighter conformation.

    • A mucoperichondrial flap can be elevated on the concave side to place full-thickness incisions into the septum. The incisions can be made in either a checkerboard grid or horizontal-line pattern.

    • Alternatively, one can remove small wedges of cartilage from the convex surface of the cartilage (see Image 8).

  • Morselization

    • This technique involves elevating the mucoperichondrium bilaterally and crushing the cartilage using Adson forceps or specially designed morselization instruments.

    • The extent of cartilage weakening is unpredictable. This technique is used infrequently because of the risk of losing dorsal support.

  • Correction for a displaced caudal septum off the maxillary crest: Excess and displaced cartilage along the nasal floor is excised, and the septum is allowed to swing back toward the midline (see Picture 9).

Closure

  • Close all mucoperichondrial incisions with 4-0 or 5-0 mild chromic suture.

  • Using a basting suture is common practice to reapproximate the septal flaps and prevent a postoperative septal hematoma.

  • Use of splints is as follows:

    • Some surgeons place silastic splints rather than use the transseptal basting suture.

    • Splints are placed bilaterally and stabilized anteriorly with a 2-0 Prolene suture.

    • They are especially useful in the presence of large septal lacerations.

  • Use of packing is as follows:

    • One-half inch wide petroleum jelly stripping or bacitracin-impregnated Telfa tampons can be used.

    • For many surgeons, nasal packing has largely fallen out of favor in uncomplicated septoplasties. Uncomfortable for patients and poorly effective as a technique for preventing septal hematoma, packing has been replaced by basting sutures and/or splinting. However, packing still should be used in cases of septal hematoma, CSF leak, or epistaxis.

Postoperative details

  • Inform patients that they need to resort to mouth breathing while nasal packing is in place. They may expect a minimal amount of bloody mucous nasal discharge, but if they develop new-onset epistaxis, they must contact their physician immediately.

  • When resting, patients should have their head elevated during the first 24-48 hours.

  • Antibiotics are usually not necessary unless nasal packing is left in place more than 24 hours.

  • Significant discomfort is not experienced by most patients after septoplasty; however, if pain relief is necessary, narcotic pain medication can be used for those patients in the first several days. If patients are experiencing severe pain, they must contact their physician immediately.

Follow-up

  • If gauze or tampon packing is used, all of it usually is removed on the first or second postoperative day.

  • Patients with splints should return to the clinic 7-10 days postoperatively for inspection of the airway and splint removal. At the postoperative visit, examine the septum for perforations and any persistent deviation. If no problems are present at this time, schedule a 6-week follow-up appointment.


COMPLICATIONS

Section 8 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Hematoma

This is a rare complication, but it deserves rapid intervention when present.

Blood pools between the cartilage and the mucoperichondrium and separates the cartilage from its blood supply. Avascular cartilage can be viable for up to 3 days. The cartilage is resorbed when the chondrocytes die, leading to septal perforation and potential loss of dorsal support.

Signs and symptoms include intense pain, swelling, hematoma of the upper lip and philtrum area, and complete nasal airway obstruction.

The risk of hematoma formation is reduced by the use of splints or a quilting mattress suture.

Management consists of drainage through a mucoperichondrial incision. Needle drainage may be inadequate. After drainage, place packing and begin administration of oral antibiotics. Pack both nasal passages to prevent shifting of the postsurgical septum. Septal splints are also useful in the postoperative management of septal hematoma, whether traumatic or postoperative.



Infection

As a complication of septal hematoma, infection can lead to rapid resorption of the septal cartilage. Prompt drainage and antibiotics minimize the risk of infection.

Infections after septoplasty can be seen in immunocompromised patients. Resident nasal florae take advantage of the mucosal injury to proliferate and invade the tissues.

TSS is rare today. Symptoms include postoperative fever, nausea, diarrhea, erythroderma, and eventual hypotension. Coating nasal packs with bacitracin ointment should reduce the growth of Staphylococcus aureus, the pathogen responsible for TSS.



Cerebrospinal fluid leak

CSF leak is a rare, but potentially very serious, complication. It is usually the result of avulsion or damage to the cribriform plate.

If a leak is recognized during the procedure, proper management includes packing and institution of antibiotics.

A postoperative CSF leak usually is managed by bed rest, nasal packing, and oral antibiotics. Spontaneous resolution usually occurs.

Vigilance for signs and symptoms of meningitis, which include headache, photophobia, nuchal rigidity, and fever, is critical.

Epistaxis

Epistaxis is an uncommon complication.

Pack both sides and begin oral antibiotics.

Nasal obstruction

Persistent obstruction after resolution of postoperative edema may be due to residual deviation that was not corrected at the time of surgery.

Alternatively, synechiae can form between the septum and turbinates at sites of mucosal injury. Synechiae are resolved by lysis and separation of the mucosal surfaces by placement of silastic splints.

A third possibility for continued nasal obstruction is a return of the cartilaginous deviation. Options at this time include another trial of medical therapy or reoperation.

Additional causes of persistent nasal obstruction include a failure to address hypertrophied turbinates at the time of the initial surgery and a failure to identify concomitant allergic or nonallergic rhinitis, which requires medical treatment for optimal management. Incompetent nasal valves are also a frequently overlooked source of nasal obstruction and become evident in the patient with persistent postoperative nasal airway obstruction. These sources of obstruction underscore the importance of a thorough preoperative assessment of the patient.

Septal perforation

Septal perforation is a complication usually encountered in the long-term postoperative period.

The patient complains of crusting, epistaxis, and a whistling sound during normal respiration.

Diagnosis is made by using anterior rhinoscopy, and the defect can be repaired with a variety of mucosal flaps if it is less than 1.5 cm.



Cosmetic nasal deformity

Cosmetic nasal deformity is a long-term complication of aggressive SMR and inadequate residual L-shaped septal strut support.

Possible deformities include widened alar rim margins, a drooping nasal tip, a retracted columnella, and a sunken dorsum with a supratip saddle formation.

This is best avoided with cartilage preservation, particularly the dorsal-caudal L-strut.



Anosmia

This is a very rare complication and is typically transient. Congestion of both septal mucosal flaps or accumulation of bloody serous fluid under the mucoperichondrial flaps may obstruct airflow to the olfactory region, producing the symptom. Careful and thorough reapproximation of the septal flaps with a quilting suture decreases the dead space under the septal flaps, and encouraging head elevation postoperatively should alleviate some of the postsurgical congestion.




OUTCOME AND PROGNOSIS

Section 9 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Literature documenting the outcomes of septal surgery is not abundant. Siegal et al and Samad et al have reported patient satisfaction and clinical improvement rates after septoplasty, and both agree that success rates for septoplasty are approximately 70%.

Some debate has occurred over the role of acoustic rhinometry in preoperative assessment and postoperative determination of objective outcomes. Unfortunately, according to Reber et al and Hardcastle et al, efforts to link rhinometry measures with subjective perception of nasal patency have met with mixed results. At present, traditional measures of outcomes must be relied upon, including subjective patient questionnaires and clinical judgment.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Nose.




FUTURE AND CONTROVERSIES

Section 10 of 12  


  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References

Endoscopic septoplasty

The enhanced visualization provided by the zero or 30° endoscope, as compared to the headlight, allows for a magnified view and increased accuracy in the evaluation of septal deviations, especially those located more posteriorly. The ability to perform limited resections and achieve better accuracy in technically challenging revisions is an advantage of the endoscopic approach. Additionally, teaching and documentation are facilitated. Several publications describing promising results have emerged, including one recent review of 111 patients by Hwang et al.



Laser-assisted septoplasty

In 1997, an article by Kamami reviewed his experience with 120 septoplasties performed using the carbon dioxide laser. The author claimed good results on patients with small-to-moderate anterior septal spurs. The technique involved shaving the spur along with the overlying mucoperichondrium in a caudal-to-cephalic horizontal direction, taking care to burn no more than a 2- to 3-mm vertical strip of mucoperichondrium. The procedure was performed in 5 minutes with the patient under local anesthesia and resulted in quick healing. A 96% good-to-remarkable subjective improvement in nasal obstruction was reported, and adverse effects were negligible. Controlled studies and long-term follow-up observation are needed before this technique has widespread use.




MULTIMEDIA

Section 11 of 12  



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References



Media file 1:  Cross-sectional area of the nasal cavity at the middle vault level. The ideal angle the caudal edge of the upperlateral cartilage makes with the septum is 10-15°.



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Media file 2:  Blood supply to the nasal septum derives contribution from the anterior and posterior ethmoidal arteries, the sphenopalatine artery, the septal branch of the superior labial artery (not labeled), and the greater and ascending palatine arteries (not labeled).



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Media file 3:  Axial CT scan demonstrating severe septal deviation. Note left-sided deflection of caudal septum and right-sided nasal airway obstruction due to bony and cartilaginous posterior deviation.



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Media file 4:  Location of the hemitransfixion and Killian incisions.



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Media file 5:  Elevation of the mucoperichondrial flap with a Cottle elevator.



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Media file 6:  (A) Transcartilaginous incision near the osseocartilaginous junction. (B) Excision of posteroinferior septal cartilage to achieve a swinging door effect. (C) Inferior strip excision of cartilage.



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Media file 7:  The external nasal approach provides directvisualization of the anterior and dorsal septum and easy access for septal repair.



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Media file 8:  One technique of incising the septal cartilageinvolves removing thin wedges from the convex side of the deviated septum to encourage midline repositioning.



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Media file 9:  Excess and displaced septal cartilage along ahypertrophied maxillary crest can be excised. A straight osteotome may facilitate removal of the bony portion.



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REFERENCES

Section 12 of 12



  • Authors and Editors

  • Introduction

  • Indications

  • Relevant Anatomy

  • Contraindications

  • Workup

  • Treatment

  • Complications

  • Outcome and Prognosis

  • Future and Controversies

  • Multimedia

  • References



  • Adams W. The treatment of the broken nose by forcible straightening and mechanical apparatus. Br Med J. 1875;2:241-55.

  • Asch M. Treatment of nasal stenosis due to deflective septum with and without thickening of the convex side. Laryngoscope. 1899;6:340-361.

  • Bailey BJ. Nasal septal surgery 1896-1899: transition and controversy. Laryngoscope. Jan 1997;107(1):10-6. [Medline].

  • Clarke RW, Jones AS. Nasal airflow receptors: the relative importance of temperature and tactile stimulation. Clin Otolaryngol. Oct 1992;17(5):388-92. [Medline].

  • Cottle MH. Newer concepts of septum surgery: present status. Eye Ear Nose Throat Monthly. 1948;27:403-429.

  • Freer OT. The correction of deflections of the nasal septum with a minimum of traumatism. JAMA. 1902;16:362-75.

  • Giles WC, Gross CW, Abram AC, et al. Endoscopic septoplasty. Laryngoscope. Dec 1994;104(12):1507-9. [Medline].

  • Hardcastle PF, White A, Prescott RJ. Clinical and rhinometric assessment of the nasal airway--do they measure the same entity?. Clin Otolaryngol. Jun 1988;13(3):185-91. [Medline].

  • Hinderer KH. History of septoplasty. In: Fundamentals of Anatomy and Surgery of the Nose. Aesculapis Publishing Co;1971:1-3.

  • Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW. Endoscopic septoplasty: indications, technique, and results. Otolaryngol Head Neck Surg. May 1999;120(5):678-82. [Medline].

  • Ingals EF. Deflections of the septum narium. Arch Laryngol. 1882;3:291-313.

  • Kamami YV. Laser-assisted outpatient septoplasty results on 120 patients. J Clin Laser Med Surg. 1997;15(3):123-9. [Medline].

  • Killian G. Die sumucose Fensterresektion der Nasenscheiwand. Arch Laryngologie Rhinologie. 1904;16:362-94.

  • Manoukian PD, Wyatt JR, Leopold DA, Bass EB. Recent trends in utilization of procedures in otolaryngology-head and neck surgery. Laryngoscope. Apr 1997;107(4):472-7. [Medline].

  • Metzenbaum M. Replacement of the lower end of the dislocated septal cartilage versus submucous resection of the dislocated end of the septal cartilage. Arch Otolaryngol HNS. 1929;9:282-311.

  • Peer LA. An operation to repair lateral displacement of the lower border of the septal cartilage. Arch Otolaryngol HNS. 1937;25:475-89.

  • Reber M, Rahm F, Monnier P. The role of acoustic rhinometry in the pre- and postoperative evaluation of surgery for nasal obstruction. Rhinology. Dec 1998;36(4):184-7. [Medline].

  • Ridenour BD. The nasal septum. In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery. Mosby-Year Book;1999:921-948.

  • Samad I, Stevens HE, Maloney A. The efficacy of nasal septal surgery. J Otolaryngol. Apr 1992;21(2):88-91. [Medline].

  • Sessions RB, Troost T. The nasal septum In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery. Vol 2. Singular Publishing;1993:786-806.

  • Siegel NS, Gliklich RE, Taghizadeh F, Chang Y. Outcomes of septoplasty. Otolaryngol Head Neck Surg. Feb 2000;122(2):228-32. [Medline].

  • Vainio-Mattila J. Correlations of nasal symptoms and signs in random sampling study. Acta Otolaryngol Suppl. 1974;318:1-48. [Medline].

  • Yanagisawa E, Joe J. Endoscopic septoplasty. Ear Nose Throat J. Sep 1997;76(9):622-3. [Medline].


Septoplasty excerpt

Article Last Updated: Mar 31, 2006




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