SEPTOPLASTY AND SUBMUCOUS RESECTION (SMR) OF THE NASAL SEPTUM

1. INTRODUCTION AND ANATOMY

• Quadrilateral (septal) cartilage anteriorly
• Perpendicular plate of ethmoid superoposteriorly
• Vomer inferoposteriorly
• Maxillary crest and palatine bone at the base

2. SUBMUCOUS RESECTION (SMR) OF THE NASAL SEPTUM

History

Definition

Indications of SMR

1. Deviated nasal septum causing symptomatic nasal obstruction not amenable to septoplasty
2. Posterior bony deviation (vomer spur, maxillary crest spur, posterior perpendicular plate deviation) - areas difficult to correct by septoplasty alone
3. Harvest of septal cartilage for grafting (tympanoplasty, rhinoplasty)
4. Combined with other nasal surgeries (e.g., turbinate reduction)
5. Surgeon preference / expertise in centres where septoplasty is not routine
6. Simple posterior deviation in adults (Dhingra)

Contraindications of SMR

1. Children below 17 years - SMR is strictly contraindicated because the septal cartilage acts as a growth centre; its removal causes arrested mid-facial development, saddle nose deformity, and failure of nasal growth (Dhingra, Hazarika)
2. Acute nasal or sinus infection
3. Uncorrected bleeding diathesis / coagulation disorders
4. High-risk anaesthetic patients who cannot tolerate the procedure

1. Uncontrolled hypertension
2. Uncontrolled diabetes mellitus
3. Pregnancy
4. Caudal or dorsal L-strut deviations (SMR cannot address these - septoplasty preferred)

Instruments Used in SMR

SMR - Procedure (Step by Step)

1. Decongestion: Cottonoids soaked in 4% cocaine or 1% lignocaine + 1:1000 adrenaline placed in nasal cavity for 10 minutes.
2. Incision - Killian incision: A vertical curvilinear incision is made through the mucoperichondrium on the convex side, 1-2 cm posterior to the caudal margin of the septum within the respiratory epithelium (not vestibular skin). This distinguishes it from the hemitransfixion incision of septoplasty which is at the caudal edge. (Cummings)
3. Flap elevation (Right side): Using the Cottle/Freer elevator, mucoperichondrial flap is elevated in the subperichondrial plane on the convex side from the incision posteriorly, then over the osseocartilaginous junction onto the vomer and perpendicular plate of ethmoid.
4. Cartilage scoring and incision: The quadrilateral cartilage is incised vertically just posterior to the incision, then horizontally at the osseocartilaginous junction. A 1 cm dorsal and 1 cm caudal strip of cartilage are preserved. The remainder is removed.
5. Flap elevation (Left side): The tunnel on the left (concave) side is created by passing the elevator through the window to elevate the contralateral mucoperichondrial flap.
6. Bone removal: The perpendicular plate of ethmoid is fractured and removed with Jansen-Middleton forceps. The vomer and maxillary crest are similarly removed where deviated.
7. Checking: The nasal cavities are inspected to confirm adequate correction of deviation.
8. Closure: The flaps are re-approximated. Quilting sutures may be placed. Nasal packing (BIPP ribbon gauze or Merocel) is placed bilaterally for 24-48 hours.

3. SEPTOPLASTY

Definition

Historical Evolution (Cummings)

• Asch (1880s): Closed displacement technique - blunt force to disrupt cartilaginous attachments; short-lived results; largely abandoned
• Ingals (1882): First described mucosal flap elevation + triangular cartilage removal (window resection)
• Freer (1902) / Killian (1904): Classical SMR
• Cottle (1947-1958): Described modern septoplasty with conservative mucosal flap + selective resection/repositioning
• Modern septoplasty: Emphasis on L-strut preservation, reconstructive techniques, spreader grafts, suture fixation

Indications of Septoplasty

1. Nasal obstruction due to deviated nasal septum (primary indication) (Dhingra, Hazarika)
2. Recurrent epistaxis from septal spur with overlying thin, traumatised mucosa
3. As part of septorhinoplasty for cosmetic correction of external nasal deformity
4. Approach for endoscopic sinus surgery (FESS) - to improve access to middle meatus, frontal recess, and sphenoid
5. Approach to pituitary fossa (transseptal transphenoidal approach)
6. Septal deviation causing contact with lateral nasal wall leading to alar collapse or obstructive sleep apnoea/hypopnoea syndrome (OSAHS)
7. Chronic sinusitis secondary to DNS causing ostial obstruction
8. Relief of nasal valve compromise due to deviation
9. Correction of caudal/dorsal L-strut deviations - the main advantage over SMR
10. Paediatric patients - when absolutely necessary (selective, after puberty preferred)

Contraindications of Septoplasty

1. Acute nasal/sinus infection (active infection - risk of spread to intracranial sinuses, meningitis)
2. Uncorrected bleeding diathesis / anticoagulation that cannot be reversed
3. High-risk anaesthetic patient with unacceptable surgical risk

1. Children <17 years - relative contraindication; can disrupt septal growth centres causing mid-facial deformity (however, less risky than SMR; may be done selectively for severe obstruction)
2. Uncontrolled hypertension
3. Uncontrolled diabetes mellitus
4. Pregnancy
5. Recent nasal trauma (<7-10 days) - attempt closed reduction first; if unsuccessful, formal septoplasty
6. Patient with unrealistic expectations regarding cosmetic outcome

Instruments Used in Septoplasty

Septoplasty - Procedure (Step by Step)

• Hemitransfixion incision (Freer's incision): Most commonly used. Curvilinear incision at the caudal edge of the septum within squamous vestibular epithelium. Provides access to the entire septum including the L-strut. Full hemitransfixion (full caudal length) or partial hemitransfixion depending on access required. Extended hemitransfixion reaches the nasal floor.
• Killian incision: 1-2 cm posterior to caudal margin, in respiratory epithelium - useful for posterior deviations only; limited caudal access.
• Transfixion incision: Full thickness through both sides - used when bilateral access needed. (Scott-Brown, Cummings)

• Using Cottle/Freer elevator, flap elevated in the subperichondrial plane (avascular; minimal bleeding if correct plane maintained)
• Cottle's spade end initiates separation; blunt end elevates posteriorly
• Raise flap on concave side first - this reduces risk of perforation by keeping the contralateral mucosa intact (Scott-Brown)
• Bilateral flaps raised only when required (S-shaped deviation)
• Extent of elevation determined by plan: can extend cephalically to harvest perpendicular plate grafts

• Scoring: Incisions on the concave surface of cartilage to release intrinsic bending forces; combined with splinting graft
• Swinging door technique: Excise excess caudal L-strut cartilage; septum swings to midline; secured to anterior nasal spine with 4-0 PDS sutures (a hole drilled in anterior nasal spine with fissure burr)
• Disarticulation of osseocartilaginous junction when dorsal deviation is due to bony attachment

• Spreader grafts (bilateral cartilage strips between dorsal septum and upper lateral cartilages)
• Batten grafts (splinting scored cartilage)
• Extracorporeal reconstruction: Entire septum removed, reconstructed on a back table using cartilage pieces sutured to ethmoid bone graft or PDS sheet, then reinserted

• Mattress sutures to straighten bowed cartilage
• Columellar-septal suture ("tongue-in-groove" - Kridel manoeuvre) - passes transcutaneously to hold caudal septum within a pocket between medial crural footplates (Cummings)
• Sutures to anterior nasal spine periosteum for caudal fixation

• Repositioning of the septum to the midline groove of the maxillary crest

• Perpendicular plate of ethmoid and vomer deviations addressed with Jansen-Middleton forceps or Hajek's punch
• Maxillary crest spurs removed with chisel/osteotome

• 4-0 chromic gut quilting (through-and-through mattress) sutures prevent haematoma formation by coaptation of the two mucosal flaps; also maintains septal position

• Hemitransfixion incision closed with 4-0 chromic gut
• Nasal splints (Silastic) may be placed if septal membrane is excoriated
• Nasal packing (Merocel or BIPP) - some surgeons avoid packing if quilting sutures are adequate

• Packing removed at 24-48 hours
• Saline nasal irrigation 4x/day
• Antibiotic ointment into vestibule after day 1
• Gentle nasal blowing permitted only after 3 weeks
• Strenuous exercise avoided for 6 weeks (Cummings)

4. SURGICAL TECHNIQUES (VARIANTS)

Endoscopic Septoplasty (Scott-Brown, Cummings)

• Introduced by Giles et al. (1994)
• Mucoperichondrium incised just caudal to the deviation; flap elevated circumferentially only around that area
• Preserves maximal mucosa
• Indicated for: limited posterior/high deviations, isolated spurs, simultaneous FESS
• Limitation: inadequate access for caudal or complex deformities

Extracorporeal Septoplasty (Scott-Brown, Cummings)

• For severely fractured, complex deformities where in-situ correction is impossible
• Entire cartilaginous (and bony) septum excised in one piece
• Reconstructed on back table, reinserted and secured to maxillary crest groove, anterior nasal spine, and upper lateral cartilages

Paediatric Septoplasty (Scott-Brown)

• Technically challenging due to growth concerns
• Conservative resection of only the deviated area; no disruption of perichondrial envelope
• Preferred after puberty; severe cases may justify earlier intervention

5. COMPLICATIONS

Complications of SMR

1. Haemorrhage
2. Septal haematoma (if bilateral flaps not coaptated)
3. Injury to contiguous structures (cribriform plate - CSF leak, anosmia)

Complications of Septoplasty

1. Mucosal tear / perforation
2. Haemorrhage
3. Damage to anterior nasal spine
4. CSF leak (rare - if dissection extends to cribriform plate)

6. DIFFERENCES BETWEEN SEPTOPLASTY AND SMR

7. SPECIAL NOTES FROM STANDARD TEXTBOOKS

Scott-Brown's Otorhinolaryngology (8th ed.)

• Emphasises that "In most cases of septal deviation, the septal L-strut is involved. SMR is not effective as it cannot address the caudal and dorsal struts."
• Four techniques of septoplasty: cutting, grafting, suturing, relocating - can be combined
• Extracorporeal septoplasty for severely fractured, deformed septum
• Advocates raising flap on concave side only (unless S-shaped deformity)
• Caudal septum fixed to anterior nasal spine with 4-0 PDS; fissure burr used to drill hole in anterior nasal spine

Cummings Otolaryngology (7th ed.)

• Describes historical evolution from Asch's closed displacement to modern preservation techniques
• Hemitransfixion preferred over Killian incision - better caudal access; less tendency to tear (within squamous epithelium)
• Cottle elevator: spade end anteriorly, blunt end posteriorly for flap elevation
• "Tongue-in-groove" suture (Kridel) for caudal septal fixation
• Persistent obstruction is the most common complication (20-30%)
• Posterior spur inadequately addressed is the most common cause of failure
• Septal splints advocated only for septal perforation or excoriated membrane (not routinely)

Dhingra (Diseases of Ear, Nose and Throat)

• SMR strictly contraindicated under 17 years
• Killian incision as standard for SMR
• Instruments enumerated: Killian speculum, Cottle elevator, Jansen-Middleton forceps, Ballenger swivel knife, Hajek punch, Luc's forceps
• Post-op: packing for 48 hours, antibiotics, steam inhalation

Hazarika (Textbook of ENT and Head & Neck Surgery)

• Detailed description of DNS classification (Mladina classification: Types I-VII)
• SMR: bilateral tunnels, removal of cartilage and bone preserving 1 cm L-strut
• Septoplasty superior for anterior/caudal deviation
• Complications well tabulated

Zakir Hussain / Maqbool (ENT for entrance examinations, Indian perspective)

• High-yield tables comparing SMR and septoplasty
• Emphasises that SMR is still in use in India for posterior bony deviation and graft harvest
• Instruments list as standard for exam purposes

8. POST-OPERATIVE CARE AND FOLLOW-UP

1. Nasal packing removed at 24-48 hours
2. Saline irrigation (4 times/day) to clear clots and debris
3. Antibiotic ointment instilled into vestibule from day 1
4. Systemic antibiotics for 5-7 days (to prevent perichondritis)
5. Analgesics
6. No strenuous exertion for 6 weeks
7. No nose blowing for 3 weeks (gentle only after that)
8. Review at 1-2 weeks for suction of crusts and synechiae check
9. Continued local care for 2-3 weeks minimum
10. Alcohol to be avoided for 1 week (increases bleeding risk)

9. QUICK REVISION TABLE (50-Mark Exam Summary)

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, 8th ed., Vol. 1, Chapter 103 - Septoplasty, pp. 1186-1192
• Cummings Otolaryngology Head and Neck Surgery, 7th ed., Chapter 29 - Deviated Nasal Septum, pp. 567-582
• Dhingra P.L. - Diseases of Ear, Nose and Throat, 7th ed.
• Hazarika P. - Textbook of ENT and Head & Neck Surgery
• Zakir Hussain / Maqbool - Textbook of ENT
• K.J. Lee's Essential Otolaryngology