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Septoplasty
1. Septoplasty
Presenter :
Dr. Taba Nitin
ENT PGT
Silchar Medical College and Hospital.
Moderator :
Dr. Shams Uddin
Prof. and HOD
Dept. of ENT and Head and neck surgery. SMCH
2. Introduction
• The term septoplasty takes its meaning from the Greek term that means
“to reshape or mold the septum.”
• Surgical techniques have subsequently been improved, especially with the
advent of endoscopy.
• Techniques used today are geared toward septal resection, but more
emphasis has been placed on preservation, realignment, or a combination
of the two.
• Most standard procedures today recognize mucosal preservation as a
primary goal and make use of a submucosal approach to the cartilaginous
and bony abnormalities.
• It is done when the septal L-strut is involved as SMR is ineffective in this
cases.
3. Historical Perspective of septoplasty and its trend.
• The earliest written treatise describing the correction of a deviated septum dates
back to the Egyptian Edwin Smith Surgical Papyrus (c. 3000 B.C.), which prescribed
closed reduction with Splinting.
• Quelmaltz : proposed daily digital pressure to correct a deviated septum in the
18th century.
• In 1875 Adams proposed closed reduction and splinting for treatment of a
deviated septum.
• While the physiological role of the nasal septum remained poorly understood
during the 19th century, surgeons emphasized on excising obstructing segments of
the septum in an atempt to relieve nasal obstruction.
4. • Krieg (1890s), performed septectomies, removing entire segments of septal
cartilage and bone along with its mucosa. These patients enjoyed a short-lived
improvement in nasal obstruction, only to suffer nasal whistling, crustng, epistaxis,
worsening nasal obstruction from turbulent airflow, and saddle nose. And later
Krieg concluded that mucosa preservation and removal of only deviated septal
cartilage could decrease complications.
• Bosworth sawed off deviated septal spurs, sacrificing the ipsilateral mucosa while
maintaining the contralateral mucosa.
• Asch (1899) proposed a full cruciate incision through the cartilaginous septum to
“destroy the resiliency” of the cartilage while preserving mucosa.
5. • In 1882 Ingals, who some call the father of septoplasty, described the targeted
resection of a deviated septum with the preservation of bilateral mucosa.
• Up to this point, there was little emphasis on the septum’s role in providing
structural support for the external nose. In fact, experts at the time considered the
septal mucosa to be the only physiologically relevant structure within the nose.
Patients with overly aggressive septal cartilage resection eventually developed
nasal tip ptosis, columellar retraction, and saddle nose deformity.
6. Era of Contemporary Septoplasty Techniques :
• Submucous resection : At the turn of the 20th century, Freer and Killian ushered in
the era of contemporary septoplasty.
• They proposed submucous resection of the deviated septum while maintaining a
dorsal and caudal strut of the cartilage of suffcient size to support the nose.
• In 1929 Metzenbaum described Swinging Door technique for Caudal Septal
Deviation.
• Cottle 1947 advocated for a more conservative “maxilla-premaxilla” septoplasty
approach.
• King and Ashley introduced extracorporeal septoplasty in 1952.
• Endoscopic septoplasty was introduced by Giles and colleagues in 1994.
7. The nasal septum
• The nasal septum has both functional and aesthetic significance.
• The septum is the main support structure of the external nose.
• It divides the nose into two cavities, regulates airflow through the nose, and
supports the mucosal lining of the nasal cavities.
8. Parts of nasal septum
• 1. Columellar Septum: It is covered on either
side by skin.
• It contains medial crura of lower lateral
cartilages, joined together with fibrous tissue.
• 2. Membranous Septum: It lies between the
columella and the caudal border of septal
cartilage and consists of only double layer of
skin. There is no bony or cartilaginous support
in membranous septum.
• 3. Septum Proper: It is covered with mucous
membrane and consists of osteocartilaginous
framework.
• Perpendicular plate of ethmoid, the vomer and
a large quadrilateral septal cartilage, which is
wedged between vomer and ethmoid plate.
• Other bones, which make very small
contributions, include
• crest of nasal bones, nasal spine of frontal
bone, rostrum of sphenoid, crests of palatine
and maxilla and the anterior nasal spine of
maxilla.
9. • A projection of the septal cartilage
called the sphenoidal process or septal
tail extends posteriorly between the
vomer and perpendicular plate of the
ethmoid.
• The septal tail can serve as an additional
source of cartilage to harvest especially
during revision rhinoplasty.
• The inferior attachment sits within the
nasal crest of the maxilla and is bound
by looser connective tissue creating a
pseudoarthrosis.
• This joint allows mobility of the septal
cartilage base during flexion thereby
reducing the risk of fracture or
dislocation with trauma.
10. Mucosa :
• pseudostratified columnar epithelium along inferior two-thirds
• olfactory epithelium along superior one third.
11. Embryology of nasal septum
• Development of the nasal airway begins during the fourth week of gestation.
• The nasal septum develops as a downgrowth from the merged medial nasal
processes and the nasofrontal process and thus defines the right and left nasal
cavities.
• During the ninth week : The nasal septum and the palatine processes begin to fuse
anteriorly.
• Fusion is completed posteriorly by the twelfth week.
• During the late embryonic period, the epithelium invaginates on each side of the
nasal septum, thereby forming diverticula known as the vomeronasal organs.
• A vomeronasal cartilage develops ventral to each diverticulum. Shortly before
birth, the vomeronasal organs begin to regress and usually disappear completely;
the vomeronasal cartilages are usually the only adult remnants..
• The perpendicular plates of the ethmoid and the nasal bones do not completely
ossify until puberty.
12. Blood supply of nasal septum
• Both the external and internal carotid arteries
contribute to the vascular supply of the nasal
septum.
External carotid internal maxillary artery.
1. Sphenopalatine artery ( supply posteroinferior
septum through posterior septal artery)
• ** The posterior septal artery is the basis of the
nasoseptal mucosal flap which is the workhorse for
endoscopic skull base reconstruction.
2. Greater palatine arteries
• enters the nasal cavity through the incisive canal.
• supply the anteroinferior portion of the septum.
3. Superior labial artery : (branch of the facial artery.)
• supply the caudal septum and columella.
Internal carotid the ophthalmic artery
• Anterior ethmoid artery (anterosuperior portion)
• Posterior ethmoid artery (posterosuperior portion)
13. The venous system
• Posteriorly : Sphenopalatine vessels pterygoid plexus
• Anteriorly : facial veins
• Superiorly: The ethmoidal veins communicate with superior ophthalmic
system. There maybe direct intracranial connections through the foramen caecum
into the superior sagittal sinus.
15. Indications of septoplasty:
• Deviated nasal septum causing nasal obstruction and recurrent headaches.
• Deviated nasal septum causing obstruction to ventilation of paranasal sinuses and
middle ear resulting in recurrent infections.
• Recurrent epistaxis from septal spur
• As a part of septorhinoplasty
• As an approach to surgeries of sphenoidal sinus, vidian nerve and pituitary gland.
16. DEVIATED NASAL SEPTUM
• Deviated nasal septum (DNS) is quite a common condition, which usually presents with
nasal obstruction.
• There is no age and sex bar but usually males are affected more than females.
• Deviated nasal septum is more common in Caucasians.
• Etiological Factors
• Accidental trauma : A lateral blow displaces the septal cartilage from the vomerine
groove and maxillary crest. A crushing frontal blow results in buckling, fractures and
telescoping of its fragments. Childhood injuries are often forgotten.
• Natal trauma : Trauma inflicted to the fetus at difficult delivery (forceps)
• Antenatal : Abnormal intrauterine postures can compress nose and upper jaw.
• Developmental : Buckling of the nasal septum can result from unequal growth between
the palate and the skull base.If septum starts growing at a more rapid rate than face, it
becomes buckled.
• Mouth breathers: Buckling of nasal septum in children can result from highly arched
palate, which occurs in mouth breathers such as in adenoid hypertrophy.
• Mass in nose : Tumors and polyps of nose
17. Types of DNS
• Anterior
dislocation (caudal
septal deviation)
• C-shaped
deformity or
reverse C-shaped
deformity
• S-shaped
deformity
• Spurs
• Thickening
18. • Type I : Mild deviation in vertical plane
• Type II : Moderate anterior vertical
deviation of cartilaginous septum in
full length.
• Type III : Posterior vertical deviation at
level of OM and middle turbinate
• Type IV : ‘S’-shaped, posterior to one
side and anterior to other
• Type V : Horizontal septal crest
touching or not touching the lateral
nasal wall
• Type VI : Prominent maxillary crest
contralateral to the deviation with a
septal crest on the deviated side
• Type VII : Combination of previously
described septal deformity types
19. Some special tests to consider before
septoplasty
1. Acoustic rhinometry:
• The sound waves are delivered to nasal cavity and the reflected sound waves are
measured (rhinogram), which include calculation of minimal cross-sectional area
of nose and nasal airway resistance.
• The first and second dips in rhinogram are caused due to nasal valve and anterior
tips of turbinates (inferior and middle) respectively.
2. Rhinomanometry or rhinometry:
• This computerized electronic technique measures transnasal pressure and
resultant nasal airflow.
• Initially, water columns and mechanical devices were used in rhinomanometry.
• More than 3 cm H2O/L/s combined bilateral resistance of adult nose at rest
indicates nasal obstruction.
22. The surgical field
• The surgical field must be optimized.
Hemostasis is obtained by:
1) working with the anesthetist to reduce cardiac output.
***Fentanyl and versed acts as a stabilizer for cardiac and
smooth muscle; these combined agents counter the
potential increase in heart rate or blood pressure that is
sometimes seen.
2) positioning the patient with the head raised about 30
degrees to reduce dependent vasocongestion,
3) Placement of neuropatties containing 1 : 1000 epinephrin.
• The (right-handed) surgeon is placed on the patient’s
right.
23. • 1% lidocaine with 1 : 100,000 epinephrine is used
with a maximum suggested dose of 4 to 7 mg/kg,
depending on the epinephrine content.
• We rarely use more than 10 mL, which is well within
the safety limits for adults.
• The local injection is performed with either a 27- or
30-gauge needle.
• Due to hydrodissection correct dissection plane can
be identified.
• The injection is started at the caudal end of the
septum, and secondary injections are performed
more posteriorly, until the mucosa is well blanched,
or until maximum volume based on patient weight is
met.
• Forceful injection is avoided to prevent retrograde
vascular communication.
• The contralateral membrane should also be injected,
and so should the area of the nasal floor around the
maxillary crest.
• After the injection is performed, waiting at least 10
minutes ensures maximum vasoconstriction.
Local Anaesthesia infiltration
24. The Incision and approach
• Insert the nasal speculum into the nose and gently
retract the slightly opened speculum revealing the
caudal septal edge.
• The No. 15 blade is then used to incise mucosa down to
and through the perichondrium on the concave side.
1. The hemitransfixion or transfixion incision:
• It is made at the caudal border of the septum.
• Allows access to the deviated caudal septum and any
posterior deflections.
• The incision is created within the squamous epithelium
of the vestibule and hence has less of a tendency to tear
under stress.
• The length of the incision depends on the access
required.
• If access is required to the whole of caudal arm of the L-
strut then a full hemitransfixion is used.
• However, if access is not required for the most posterior
parts of the septum, then a partial hemitransfixion
would suffice.
• If access is required to the floor of the nasal cavity then
an extended hemitransfixion incision is used.
• In certain conditions, both mucosal flaps are raised (e.g.
S-shaped septal deformity)
25. Open Rhinoplasty approach :
• Some may still approach the septum through an
open rhinoplasty approach using marginal and
transcolumellar incisions.
• In the open approach to the septum, after a
transcolumellar skin incision is made, the medial
crura are separated, and the caudal septum is
then identified.
• Tip support is significantly weakened with this
open dissection technique, therefore we reserve
this approach for those undergoing an open
approach to septal perforation repair or in
complex cases.
26. Plane identification and
mucoperichondrial flap elevation
• Identification of the proper plane. This can be
achieved by scoring the area to find the desired
plane.
• The Cottle elevator, with its two dissecting faces—one
shaped like a sharpened spade, the other more flat
and dull is used to raise the envelope under direct
vision.
• The sharper, spadelike end is used first to begin the
dissection in the submucoperichondrial plane.
27. • After the dissection is started, the flat
and dull end efficiently elevates the
envelope in an atraumatic fashion.
• Elevate the envelope with a wide front
to ensure the best visibility and to
decrease the risk of mucosal tearing.
• Longer specula are now used as the
dissection proceeds posteriorly.
28. • When the bony osseocartilaginous junction is
reached, this junction is disarticulated to gain
access to the opposite side of the bony septum.
• Carefully raise the mucosal flap from the opposite
side of the bony septum.
• Disarticulation of the quadrilateral cartilage from
the maxillary crest.
• Septum moved to midline.
• Often a sliver of bone or cartilage needs to be
removed.
• The 1 cm of bony-cartilaginous junction at the L-
strut is left undisturbed if possible but often this
area requires special attention.
29. Managing the spur
• Raising the flap over a septal spur can be
challenging as the perichondrial fibres of the
cartilaginous septum and the periosteal fibres
of the maxillary crest are interwoven.
• The mucoperichondrial flap is raised over the
quadrilateral cartilage and the bony septum;
this constitutes the anterior tunnel over the
spur.
• Then another subperiosteal tunnel is raised
posterior to the septal spur which constitutes
the posterior tunnel.
• Connecting the two tunnels directly helps to
avoid mucosal tears.
• The dissection may be eased with the use of
the sharper spade end of the Cottle elevator
30. • The risk of membrane fenestration is
greatest in the area of a spur.
• To mobilize the bony deviation or
spur, Becker septal scissors are used to
make cuts in the bony septum above
and below the deviated septal
segment or spur.
• To prevent cribriform plate injury, the
superior bony septum is never
manipulated without first performing
a superior septal incision or cut. Even
then, any posterior septal removal is
done within one rotational plane.
31. • Removal of the freed segment with a
nonbiting forceps completes the resection
using wide-mouthed Watson-Williams forceps
32. SEPTOPLASTY TECHNIQUES
The deviated septum can be addressed by :
• 1) Cutting techniques
• 2) Grafting techniques
• 3) Suturing techniques
• 4) Relocating techniques.
The techniques can be used alone or in combination.
33. CUTTING TECHNIQUES
• Scoring of the septal cartilage on the concave side allows the septum to become straight.
• The septum will be kept in position by the scar tissue in grooves created by scoring on the
concave side
• In S-shaped septal deformities, the scoring needs to be done on the concave segments on both
sides; hence the need for raising bilateral mucoperichondrial flaps.
• In the swinging door technique, an appropriate amount of caudal L-strut is excised to allow the
septum to return to the midline.
• The septum then needs to be secured to the midline again; this can be achieved by suturing
the septum back to the anterior nasal spine or its periosteum.
• To apply sutures to the anterior nasal spine, a hole is made in the bone using a strong
hypodermic needle or using a drill with a Fissure burr.
• The septum is then secured in place with 4 x 0 PDS sutures.
34. GRAFTING TECHNIQUES
• This technique involves harvesting a suitable piece of perpendicular plate of ethmoid which is then
thinned down using a large diamond burr (e.g. 5 mm diamond burr).
• The graft is then perforated using a Fissure burr and it is splinted against the concave side of the
septum.
• Both septal cartilage and septal bone can be used.
• The perpendicular plate of ethmoid is stronger and thinner compared to the septal cartilage and so is
used more frequently.
• Care must be taken to position the bony strut a few millimetres from the septal edge so that it is not
felt by the patient and it does not cause obstruction for dorsal reconstruction (e.g. spreader grafts).
• A fine absorbable or non-absorbable suture is used to secure the graft to the septum (e.g. 5 × 0 PDSR).
• The deviation of the dorsal L-strut
can be corrected by spreader grafts
too.
• The concave part of the dorsal
septum is scored and returned to
midline; it is then splinted by
spreader grafts and secured in
place by sutures (e.g. 5 × 0 PDSR).
35. SUTURING TECHNIQUES
• A mattress suture can be used to
control the septal curvature.
• In this technique, the septum is first
scored (preferably underscored) just
enough to make it pliable so it can be
shaped and kept in shape by fine
sutures.
• The entrance and exit sutures are
placed on the convex side and the knot
is incrementally tightened until the
desired position and shape is achieved.
• A fine non-absorbable suture (e.g. 5 × 0
ProleneR) is used for this purpose and
bilateral mucoperichondrial flaps are
raised so that the suture is covered by
the septal mucosa.
Bow-Tie Mattress Suture
Universal horizontal mattress suture
36. Some other suturing techniques
• A, When reapproximating septal segments, a
simple interrupted or figure-of-eight suture does
not provide support for the segments and can lead
to overlapping.
• B, A Wright suture stabilizes the fractured segments
to one mucoperichondrial flap and to each other to
maintain the proper alignment. To perform this
maneuver, a figure-of-eight suture is made that
includes the contralateral mucoperichondrial flap in
both the sutures through the superior and inferior
segments.
• Quilting mattress sutures of the septal flaps
prevent hematomas and hemorrhage.
37. RELOCATING TECHNIQUES
• These techniques are used when the
septum is dislocated off the midline and it
only requires reinsertion onto the maxillary
crest.
• A deviated septum off to the side of the
maxillary crest must be separated from the
bony perpendicular plate.
• The inferior cartilaginous portion must be
trimmed and secured in its midline position
• Suture the septum either onto the
periosteum of the anterior nasal spine or
to the actual bone by drilling a hole onto it.
• Fine absorbable or non-absorbable sutures
can be used for this purpose.
• Often a deviated caudal septum can be
improved by door-stop technique where
the septal cartilage is dissected free along
the maxillary crest and is relocated over
the nasal spine which acts as a door stop
and secures the caudal septum in a
straighter position.
38. Reskeletonizing the septum
• Postoperatively, septal flaps without
interposed cartilage adhere to one
another without supporting structure;
these weakened flaps are susceptible to
injury and potential perforation.
• Crushed cartilage placed between the
mucoperichondrial flaps prevents
motion of the membrane with
inspiration or expiration, helps prevent
septal perforation, and allows easier
reentry if another procedure is required.
• After reskeletonization, the entire septal
flap from anterior to posterior is
mattressed with a continuous 5-0 plain
stitch; a curved needle should be used
for this purpose
39. Tongue-in-groove maneuver by
Kridel and colleagues for caudal
septal deviations.
• Bilateral mucoperichondrium
elevated.
• After the septum along the floor and
the crest are straightened, as
described above, and after creation
of the swinging door, the length of
the septum is evaluated.
• If the septum is long, a conservative
trim is warranted.
• Otherwise, the caudal margin can be
repositioned to the midline nasal
spine, secured, and sandwiched
within a pocket created between the
medial crural footplates.
• A columellar-septal mattress suture
of 4-0 chromic gut is passed
transcutaneously and holds the
caudal septal margin and medial
crura in place.
40. Preoperative image of a caudal septal deviation
Postoperative view after septorhinoplasty using
swinging door and tongue-in-groove
techniques.
41. SPECIAL SEPTOPLASTY
CONSIDERATIONS
1. Endoscopic septoplasty:
• Improve visualization
• It also allows minimal access dissection to reach isolated deviated parts of the
septum particularly of more cephalic septal deformities..
• Endoscopic septoplasty can be used concomitantly along with sinus surgery.
• It is also an effective teaching tool.
2. Extracorporeal septoplasty :
• In cases of a severely fractured and deformed septum.
• The septum (both cartilaginous and the bony segment) is excised in one piece as
intact as possible.
• The septum is then measured and a template is made to represent the new
septum.
42. 3. Paediatric septoplasty :
• There remains controversy about the optimal age and Extent of septal surgery in
the paediatric population.
• Studies have demonstrated that septal surgery performed in children as young as 6
years old provides long-term satisfactory outcomes.
• The most important aspect of surgery is to resect the cartilage conservatively and
to avoid disrupting the endochondral ossification plates if possible.
• Excision should be kept to minimum and any excised segment should be reinserted
after remodelling.
43. POSTOPERATIVE CARE
• A light nasal pack is placed to prevent large clot accumulation.
• Tight packs are avoided as there is tendency to adhere to mucosa, cause pain, and
create bleeding when removed.
• A single- or double-folded nonstick cotton pad impregnated with gentamicin
cream is inserted before extubation and is removed the day after surgery.
• The use of cream, rather than petroleum-based ointment, may decrease the
initiation of petroleum cysts during this early healing phase.
• After the nasal packs are removed, a thrice-daily regimen of saline flushing of the
nose is initiated.
• Twenty-four hours after the procedure, when incisions are closed and sealed, the
patient is instructed to start the instillation of antibiotic ointment into each
vestibule.
• Gentle suctioning on postoperative days 5 through 7 and continued local care for
at least 2 to 3 weeks allows for adequate healing.
• Gentle nose blowing is permitted after the third week, and strenuous exercise is
discouraged for a total of 5 weeks.
44. COMPLICATIONS OF SEPTOPLASTY
• Most common : Persistence in the subjective complaint of nasal
obstruction.
• septal hematoma
• septal perforations
• Nasal shape changes (e.g., tip ptosis, dorsal nasal saddling)
• synechiae
• Excessive bleeding
• CSF rhinorrhea
• Wound infection
• Septal abscess
• Toxic shock syndrome
• Sensory changes : anosmia or dental anesthesia
45. It is interesting to note that the goal of septal surgery is
the same as it was 100 years ago.. but now the process
has changed, the nasal surgeon strives to maximize the
symptomatic improvement of nasal obstructive
complaints and minimize the risks involved in such a
pursuit
