Septoplasty — Comprehensive Review

1. Definition & Overview

Cummings Otolaryngology Head and Neck Surgery (Ch. 29)

2. Anatomy & Embryology

Embryological development

• Nasal septum develops from the merged medial nasal processes and the nasofrontal process beginning around the 4th week of gestation
• The septum and palatine processes begin to fuse anteriorly by the 9th week, with posterior fusion completed by the 12th week
• Vomeronasal cartilages — narrow strips inferior to the septal cartilage — are vestiges of vomeronasal organs; useful as graft material when other sources are exhausted

Septal anatomy

1. Junction with the anterior nasal spine of the maxilla
2. The keystone area — confluence of nasal bones, quadrangular cartilage, upper lateral cartilages (ULCs), and perpendicular plate of ethmoid — crucial for dorsal stability

• Divides nasal cavity into two chambers
• Supports nasal dorsum
• Maintains columella and tip shape
• Enables laminar airflow and humidification/filtration

3. Indications

Primary indication

• Nasal obstruction (unilateral or bilateral)
• Recurrent sinusitis from obstructed drainage
• Recurrent epistaxis secondary to septal varices (anterior cartilage deviation → turbulent airflow → mucosal drying → bleeding)
• Impaired olfaction
• Obstructive sleep apnea with anatomic contribution
• Snoring

Combined indications

• As access for functional endoscopic sinus surgery (FESS) when deviation impairs visualization
• Combined with rhinoplasty (septorhinoplasty) for cosmetic + functional correction
• Combined with turbinoplasty for turbinate hypertrophy

Note: ~40% of adults have a deviated septum, but most are asymptomatic. Surgery is reserved for symptomatic patients. Up to 90% prevalence of DNS has been quoted; symptoms must correlate.

4. Contraindications

• Pediatric patients — generally deferred until skeletal maturity due to theoretical risk of disrupting nasal and facial growth (though this risk appears low per recent evidence)
• Active sinonasal infection
• Bleeding disorders (relative; manage medically first)
• Realistic expectation mismatch — if obstruction is primarily mucosal/inflammatory rather than structural, medical therapy is first-line

5. Preoperative Assessment

History

• Duration and severity of obstruction (NOSE score — Nasal Obstruction Symptom Evaluation — used to quantify)
• Side-specific or alternating obstruction
• Prior nasal trauma or surgery
• Epistaxis, snoring, OSA symptoms
• Response to decongestants, steroids

Physical examination

• Anterior rhinoscopy — assess caudal septum position, spurs
• Cottle sign — lateralizing cheek skin may open the nasal valve and relieve obstruction; suggests valve rather than pure septal pathology
• Nasal endoscopy — evaluate posterior septum, turbinates, sinus ostia
• External nose — assess dorsal deviation, tip position, columella

6. Surgical Technique

6a. Incisions

6b. Plane of Dissection

• Subperichondrial/subperiosteal plane is mandatory — ensures minimal bleeding, stronger flaps, lower perforation risk
• Technique: Incise mucosa down to and through perichondrium → "scrape" cartilage to confirm plane → elevate with Cottle elevator (spade end first to start; blunt end for posterior elevation) or Freer elevator (straighter, higher perforation risk)
• Wide-front elevation reduces tears
• Floor dissection: elevate above and below any maxillary crest deviation, create two tunnels, then connect them to avoid tearing

6c. Cartilage and Bone Resection

• After bilateral flap elevation, use beveled edge of Cottle elevator to incise cartilage at bony-cartilaginous junction
• Carry incision anteroinferiorly
• Preserve L-strut: minimum 1 cm dorsal + 1 cm caudal cartilage
• Deviated cartilage can be:
  • Scored (partial-thickness cuts on the concave side to release intrinsic forces)
  • Crushed (disrupts cartilage memory)
  • Morselized
  • Resected if grafts needed (only obstructing portion; avoid routine total resection)
• Posterior bony deviations (vomer, perpendicular plate): addressed with Takahashi rongeurs, Kerrison punch, or osteotomes
• 50% of inspired air passes along the nasal floor → maxillary crest deviations must not be ignored

6d. Reskeletonization

• Prevents flap motion with respiration
• Reduces perforation risk
• Facilitates reentry at future revision surgery

6e. Closure and Packing

• Quilting mattress sutures (4-0 chromic gut, curved needles, running trans-septal) reapproximate flaps, eliminate dead space, prevent hematoma — obviate the need for hard internal splints in most patients
• Any mucosal tear → repair with 5-0 plain suture; bilateral tears → + interposition graft of crushed cartilage
• Avoid intranasal packing (increases patient discomfort; risk of pressure necrosis)
• Avoid hard nasal splints

7. Special Situations

7a. Caudal Septal Deviation (Septoplasty and the Caudal Septum)

• Bilateral mucoperichondrial elevation is essential
• Deviated inferior edge (shifted off crest) or truly dislocated caudal margin:
  • Straighten floor/crest deviations
  • Create "swinging door" — mobilize septum to midline
  • Evaluate length; conservative trim only if too long
  • Tongue-in-groove maneuver (Kridel, 1999; originally Rethi 1934): caudal septal margin repositioned to midline, sandwiched in pocket between medial crural footplates, secured with columellar-septal mattress suture (4-0 chromic gut) — reduces need for caudal trimming
• Severely gnarled caudal septum → may excise and replace with reconstruction graft (autologous septal cartilage or other cartilage)
• Extracorporeal septoplasty (for markedly deviated septum): cartilaginous septum completely removed, straightened extracorporeally, fixated, replanted, stabilized with spreader grafts to maxillary spine and dorsal septum. Risk: dorsal irregularities, tip de-projection

7b. Septoplasty with Correction of the Nasal Valve

• Internal nasal valve (15° angle between ULC and septum) is the point of greatest resistance in the nasal airway
• Valve compromise: seen in narrow middle-third nose, "tension septum" (high dorsum tethered to upper lip), post-rhinoplasty inverted-V deformity
• Spreader grafts (cartilage strips placed between dorsal septum and ULCs): open the internal valve angle, straighten bowing septum, reconstitute ULC attachment
• ULCs must be released from dorsal attachments and reattached after surgery to prevent valve compromise

7c. Septoplasty with Septal Perforation Repair

• Septal perforation → turbulent airflow → crusting, epistaxis, whistling, eventual nasal saddling and tip ptosis
• Repair: external rhinoplasty approach with nasal floor advancement flaps + interposition graft (temporalis fascia or acellular human dermis)

7d. Septoplasty and the Crooked Nose

1. Septoplasty + bilateral ULC release from dorsal septum
2. Medial and lateral osteotomies
3. Spreader grafts at point of greatest bowing
4. Lateral onlay grafts if needed
5. Reattachment of ULCs to dorsal septum

7e. Septoplasty Combinations: The Rule, Not the Exception

• ~20–30% of patients have inadequate symptom relief from septoplasty alone (drops to <10% with optimal patient selection and technique)
• Frequent adjuncts:
  • Inferior turbinate reduction (up to 20% of patients have turbinate hypertrophy contributing to obstruction; 50% of airflow passes along nasal floor)
  • Turbinate medical therapy first in allergic/non-allergic rhinitis
  • FESS when sinusitis co-exists
  • Spreader grafts / valve surgery

8. Postoperative Care

• Nasal saline irrigation (initiated postoperatively)
• Analgesics
• Antibiotics — commonly prescribed perioperatively (though recent systematic review questions necessity; PMID 38677149)
• Splints (silastic internal splints if used) removed at 5–7 days
• Avoid nose blowing 2–3 weeks
• No strenuous activity 2–3 weeks
• Mild postoperative oozing expected; significant bleeding warrants evaluation

9. Complications

10. Special Populations

Pediatric Patients

• Septoplasty generally not recommended until skeletal maturity (~15–17 years in females, ~17–18 in males)
• Concern: disruption of septal growth centers may impair facial/nasal development
• However, risk appears low per recent systematic reviews — some advocate limited surgery for severe obstruction, OSA, or chronic mouth-breathing affecting facial development
• 2024 systematic review (PMID 38035612) supports conservative approach with case-by-case decision-making

Allergic Rhinitis + DNS

• Combined pathology common
• 2024 meta-analysis (PMID 39572690) confirms septoplasty provides significant benefit in patients with allergic rhinitis + deviated septum, beyond medical therapy alone

11. Endoscopic Septoplasty

• Advantages: improved visualization of posterior deviations; avoids need to change instruments during combined FESS; allows direct visualization of the septum without a headlight
• Technique for combined FESS: Begin ESS on the contralateral side to the deviation (better visualization, less septal trauma risk) → perform septoplasty → complete second side

12. Key Principles (Takeaways)

1. Preserve the L-strut (1 cm dorsal + 1 cm caudal) to maintain tip and dorsal support
2. Subperichondrial dissection is non-negotiable to prevent tears and hematoma
3. Hemitransfixion incision is preferred for most cases
4. Reskeletonize flaps with crushed cartilage after resection
5. Quilting sutures replace the need for packing or hard splints
6. Repair all mucosal tears intraoperatively; bilateral tears → add interposition graft
7. Address the whole septum — cartilaginous + bony deviations; overlooking posterior spurs is the most common cause of persistent obstruction
8. Septoplasty alone is often insufficient — always assess turbinates, nasal valves, and sinuses
9. Avoid aggressive caudal resection — tongue-in-groove or reconstruction is preferable to trimming
10. Set realistic expectations — even with excellent technique, some degree of cartilage memory exists

• Cummings Otolaryngology Head and Neck Surgery, Ch. 29 — Septoplasty
• K.J. Lee's Essential Otolaryngology, Nasal Septum Management section
• Textbook of Family Medicine 9e, Deviated Septum
• Recent evidence: PMID 38677149 (antibiotics in septorhinoplasty, 2024 SR/MA), PMID 38035612 (pediatric septal surgery, 2024 SR), PMID 39572690 (septoplasty in allergic rhinitis, 2024 MA)