Septoplasty and Nasal Procedures

Overview

• Divides the nasal airway into two chambers
• Supports the nasal dorsum
• Maintains the shape of the columella and tip

Indications

• Nasal airway obstruction due to traumatic deviation or developmental abnormality
• Impaired olfaction, humidification, and filtering of air
• Chronic sinus disease related to anatomic septal deviation
• External nasal deformity
• Severe epistaxis caused by septal varices (from anterior cartilage deviation causing turbulent airflow, mucosal drying, and irritation)
• Combined rhinoplasty cases requiring cartilage grafts

Treatment must be individualized — some patients with large deviations have few complaints, while others with minor deviations complain significantly.

Anatomy Relevant to Septoplasty

• Quadrilateral (septal) cartilage — anterior, dominant cartilaginous component
• Perpendicular plate of ethmoid — posterior bony septum
• Vomer — inferior bony septum
• Nasal crest of maxilla and palatine bone — floor attachment

Historical Evolution of Technique

Surgical Technique (Modern Septoplasty)

Incisions

• Hemitransfixion incision — along one side of the caudal septum; used for most straightforward deflections
• Killian (high transfixion) incision — posterior to the caudal strut; preserves the anterior caudal septum
• Full transfixion incision — through both sides; used when complete access is needed
• Endonasal incision
• External (open) rhinoplasty approach — for caudal deflections or combined rhinoplasty cases

Plane of Dissection

• Elevation must be in the subperichondrial/subperiosteal plane
• Staying in the correct plane minimizes mucosal tears and bleeding
• Bilateral flap elevation is needed for caudal deflections

Cartilage and Bone Work

• Scoring, morselization, or crushing of cartilage to remove intrinsic tension
• Removal of deflected bony components (vomer, perpendicular plate spurs)
• A minimum 1.5 cm L-strut (dorsal + caudal strut) must be preserved to maintain structural support and prevent saddling or tip ptosis
• Extracorporeal septoplasty: The entire septum is removed, straightened on a back table, and reinserted — reserved for markedly deviated or severely traumatized septa

Closure

• Bilateral flaps are reskeletonized with straightened or crushed cartilage
• Mattress sutures (absorbable, curved needle) approximate the flaps and eliminate dead space — preferred over nasal packing
• Any mucosal tears are repaired primarily
• Avoid intranasal packing or hard nasal splints (associated with complications)

Combined Procedures (Common Combinations)

Septoplasty + Turbinate Reduction

Septoplasty + Nasal Valve Correction

• Spreader grafts — stent the internal nasal valves, widen the valve angle
• Alar batten grafts — bolster the external valve if the lower lateral cartilage (LLC) support is compromised
• The Cottle maneuver (lateral cheek traction) and gentle lateral displacement of the ULC help assess valve contribution

Septoplasty + Rhinoplasty (Septo-rhinoplasty)

• Bilateral ULC release from dorsal septum to release intrinsic forces and straighten the dorsum
• Followed by medial and lateral osteotomies if needed
• Spreader grafts or lateral onlay grafts may complete dorsal straightening
• Harvested septal cartilage serves as graft material

Septoplasty + Endoscopic Sinus Surgery (ESS)

• Deviated septum may impair endoscope access to sinus ostia
• ESS is typically started on the contralateral side first for better visualization and to reduce septal trauma risk
• Septoplasty is then performed before completing the ipsilateral sinus work

Special Situations

Caudal Septal Deviation

• The most technically demanding area — inadequate correction is a leading cause of persistent obstruction
• Approaches: caudal resection with repositioning, tongue-in-groove technique (suturing caudal septum to anterior nasal spine), or extracorporeal septoplasty

Crooked Nose

• Septum is often the structural driver of external dorsal deviation
• Bilateral ULC release + septoplasty ± osteotomies ± spreader grafts required

Septal Perforation Repair

• Recognized complication of septoplasty (must be discussed preoperatively)
• Prevention: immediate intraoperative closure of any mucosal fenestrations, correct subperichondrial plane dissection, reskeletonization with crushed cartilage
• Consequences of untreated perforation: turbulent airflow, crusting, epistaxis, whistling, saddle nose deformity, tip ptosis, chronic osteitis
• Repair: intranasal advancement flaps + connective tissue interposition graft (temporalis fascia or acellular human dermis); external rhinoplasty approach preferred for access

Pediatric Septoplasty

• Generally not recommended in younger children due to concern about disrupting nasal and facial growth (though evidence suggests this risk is low)
• Chronic mouth-breathing secondary to obstruction can itself negatively affect facial development

Complications

Key Principles (Best Practices)

1. Choose the optimal starting incision based on the location of the deviation
2. Elevate bilateral mucosal flaps for caudal deflections
3. Avoid mucosal tears through meticulous dissection in the correct subperichondrial plane
4. Reskeletonize flaps with straightened or crushed cartilage before closure
5. Close with absorbable mattress sutures — avoid packing and hard splints
6. Repair any mucosal tear immediately
7. Preserve the L-strut (≥1.5 cm dorsal + caudal)
8. Address all concurrent pathology (turbinates, valves) in one setting

1. General ENT exam sequence
2. Ear exam
3. Nose exam
4. Throat/larynx exam
5. Red flag findings and documentation template