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 infections.

A deviated nasal septum that interferes with proper function of the nose is corrected by septoplasty.

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.

Under Construction

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.

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 : 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 : 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 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 .

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.

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.

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 care:

• 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.

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.

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.