The nasal septum is made of cartilage and bone
covered with a lining (mucosa). It divides
the nose into two separate chambers, left
and right. Normally, the septum is
relatively straight, with right and left
nasal cavities of similar size.
Occasionally, however, the nasal septum may
be severely bent, or deviated – enough to
encroach upon a nasal cavity. A deviated
nasal septum may develop as the nose matures
or could result from an injury to the nose.
Common complications are breathing
interference and a predisposition to sinus
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A deviated nasal septum that interferes with proper function of the
nose is corrected by septoplasty.
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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.
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.
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
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.
Pituitary tumor resection is possible
through the transseptal-transphenoidal
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The surgery can take place under general or local anesthesia. using
a headlight or an endoscope, the surgeon
makes an incision inside the nose, lifts up
the lining of the septum, and removes and
straightens the deviated portions of the
septal bone and cartilage.
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
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
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.
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
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 include preoperative injections, technique via
endonasal and external nasal approaches,
elevation of the mucoperichondrial and
contralateral mucoperichondrial flaps,
correction of deviation, and closure.
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
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
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
Maximum dose of lidocaine with epinephrine
is 7 mg/kg.
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
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
Elevation of the contralateral
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
Gain access to the contralateral
mucoperichondrium by removing a strip of
cartilage along the inferior border adjacent
to the maxillary crest (see
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
This approach provides a generous view of
the septum and is an ideal approach for
septal perforation repair.
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
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
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
Cartilaginous incisions or scoring of
This technique weakens the tensile
strength of the cartilage and, after
postoperative splinting, encourages
it to scar into a straighter
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
This technique involves elevating
the mucoperichondrium bilaterally
and crushing the cartilage using
Adson forceps or specially designed
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
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
use of splints is as follows:
Some surgeons place silastic splints
rather than use the transseptal
Splints are placed bilaterally and
stabilized anteriorly with a 2-0
They are especially useful in the
presence of large septal
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
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
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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
When resting, patients should have their
head elevated during the first 24-48
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.
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.
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In the early period following the surgery,
there is usually some tenderness and
swelling inside the nose. Over time, because
the nasal cartilage has some "memory," there
can be a tendency for the septum to reshape
itself back toward its deviated position.
Other complications from the surgery are
very rare, but can include bleeding, change
in shape of the nose, some numbness of the
front teeth, or impairment and even loss of
the sense of smell.
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
Signs and symptoms include intense pain,
swelling, hematoma of the upper lip and
philtrum area, and complete nasal airway
The risk of hematoma formation is reduced by
the use of splints or a quilting mattress
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.
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
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
Vigilance for signs and symptoms of
meningitis, which include headache,
photophobia, nuchal rigidity, and fever, is
Epistaxis is an uncommon complication.
Pack both sides and begin oral antibiotics.
Persistent obstruction after resolution of
postoperative edema may be due to residual
deviation that was not corrected at the time
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
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 is a complication usually
encountered in the long-term postoperative
The patient complains of crusting, epistaxis,
and a whistling sound during normal
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
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
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.
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