The document is a detailed overview of septoplasty, a surgical procedure to correct a deviated nasal septum, highlighting its history, techniques, indications, and contraindications. It covers embryology, the anatomy of the nasal septum, various surgical approaches, and special considerations, including pediatric cases and postoperative care. Additionally, it discusses complications associated with the procedure and references relevant literature in otorhinolaryngology.

1. Septoplasty
Dr. Nirajan Khadka
First year Resident
ENT-HNS, PoAHS
Moderator: Asso. Prof Dr. Akash Mani Bhandari

2. Introduction
“Septoplasty” takes its meaning from the Greek term that means “to reshape or mold
the septum”
An operation designed to replace a deviated nasal septum in the midposition by
dividing almost all its attachments and leaving the quadrilateral cartilages attached
to a flap of mucosa to preserve its viability

3. • Techniques used today are still 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 submucous cartilaginous and bony approach
• In most cases of septal deviation, the septal L-strut is involved
• Septoplasty techniques are needed to address these problems and the approach
should provide access to the L-strut.

4. Septal surgery history
Edwin Smith Surgical Papyrus (dated 17th century BC): World's oldest surgical document &
only surviving copy of a part of an Ancient Egyptian textbook on trauma surgery written in
3500 B.C.

5. Quelmaltz proposed daily digital pressure to correct a deviated septum in 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 attempt to relieve nasal obstruction

6. In 1890 Krieg described a technique of mucosal resection in which the deflected
cartilaginous segment, along with overlying mucosa, was removed in its entirety
Patients suffered nasal whistling, crusting, epistaxis, worsening nasal obstructions
from turbulent airflow, saddle nose
Later Kreig concluded mucosal preservation and removal of only deviated septal
Cartilage could decrease complications
Bosworth sawed off deviated septal spurs, sacrificing ipsilateral mucosa while
Maintaining the contralateral mucosa

7. 1899- Asch purposed a full cruciate incision through the cartiliginous septum to
“ destroy the resiliency” of the cartilage while preserving mucosa
• Bosworth operation (late 19th century): deviated part of septum amputated along
with mucosa
• Asch (1899): full thickness cruciate incisions on septal cartilage
• Freer (1902): SMR of total septal cartilage
• Killian (1904): SMR with preservation of dorsal & caudal portion of septal cartilage
• Metzenbaum (1929): Swinging door technique for caudal septal dislocation
• Peer (1937): Removal of caudal septum & replacement after its alteration
• Cottle (1948) : Maxilla-Premaxilla septoplasty

8. • The nasal airway is composed of two nasal cavities, each with a medial and a lateral
wall as well as a floor
• Medial nasal wall: This is mainly formed by the nasal septum which in itself is
composed of bony, cartilaginous and membranous parts. The columella forms the
most caudal part of the medial wall
• Lateral nasal wall: This is formed by the turbinates,fibrofatty tissue and cartilages
(sesamoid cartilages,accessory cartilages, upper lateral cartilage and the
lateral crus of the lower lateral cartilage)
• Nasal floor: This wall is formed by the floor of the nasal cavity and the nasal
vestibule sill.

9. Nasal septum
The nasal septum has both functional and aesthetic significance
Main support structure of the external nose
Divides the nose into 2 cavities; regulates airflow through the nose and supports the
mucosal lining of the nasal cavities

10. Parts of Nasal Septum
1. Columellar septum:
It is covered on either side by skin.
Contains medial crura of lower lateral cartilages,
Joined together with fibrous tissue
2. Membranous Septum:
-Lies between the columella and the caudal border
of septal cartilages and consists double layer of skin
-No bony and cartilaginous support

11. 3. Septum Proper
It is covered with mucous membrane and consists of osteocartilginous framework
Perpendicular plate of ethmoid, the vomer and a large quadrilateral septal cartilage,
which is wedged between vomer and ethmoid plate
Other bones, includes Crest of nasal bone, nasal spine of frontal bone, rostrum of
sphenoid, crests of palatine and maxilla and the anterior nasal spine of maxilla

12. 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 sepal 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 loose
connective tissue creating a pseudoarthrosis
The joint allows mobility of the septal cartilage
base during flexon thereby reducing the risk of fracture
or dislocation with trauma

13. Embryology of Nasal Septum
Begins during 4th
weeks of gestation
The nasal septum develops as a downgrowth from merged medial nasal processes and
the nasofrontal process and thus defines right and left nasal cavities
During 9th
week: The nasal septum and the palatine processes begin to fuse anteriorly
Fusion is completed posteriorly by 12th
week
During the late embryonic period, the epithelium invaginates on each side of the
nasal
septum; forming diverticula known as the vomeronasal organs

14. A vomeronasal cartilages develops ventral to each diverticulum; the vomeronasal
cartilages are usually the only adult remnants
The perpendicular plates of the ethmoid and the nasal bones donot completely
ossify until puberty

15. Indications of Septoplasty
1. Deviated septum causing nasal obstruction on one or both sides.
2. As a part of septorhinoplasty for cosmetic reasons.
3. Recurrent epistaxis usually from the spur.
4. Sinusitis due to septal deviation.
5. Septal deviation making contact with lateral nasal wall and causing headaches.
6. For approach to middle meatus or frontal recess in endoscopic sinus surgery when
deviated septum obstructs the view and access to these areas.
7. Access to endoscopic dacryocystorhinostomy operation in some cases.
8. As an approach to pituitary fossa (trans-septal transsphenoidal approach).
9. Septal deviation causing sleep apnoea or hypopnoea syndrome.

16. CONTRAINDICATIONS
1. Acute nasal or sinus infection.
2. Untreated diabetes.
3. Hypertension.
4. Bleeding diathesis

17. 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 cavity resistance
The first and second dips in rhinogram are caused due to
nasal valve and anterior tips of turbinates(inferior and
middle) respectively

18. 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 H20/L/s combined bilateral resistance of adult nose at rest indicates
nasal obstruction

19. The surgical field
The surgical field must be optimized
Hemostasis is maintained by:
1. Working with the anesthesist to reduce cardiac output if done under GA
2. Positioning the patient with the head raised about 30 degrees to reduce
dependent vasocongestion
3. Placement of neuropatties containing 1:1000 epinephrine

20. Local Anaesthesia infiltration
- 1% Xylocaine with 1:100,000 epinephrine is used with a maximum suggested dose
of 4 to 7 mg/kg
- Injection is performed with either a 27- or
30- gauge needle
- Due to hydro dissection correct dissection plane
can be identified
- The injection is started at the caudal end of the septum,
and secondary injection 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
- Waiting at least 10 minutes ensures maximum vasoconstriction

21. TYPES OF SEPTAL INCISIONS IN SEPTOPLASTY
1. Killian’s: In the nasal mucosa, cephalic to the caudal end of the septum
2. Transfixion: Through and through incision, close to but caudal to caudal end of the
septum.
3. Hemitransfixion: Same as the transfixion incision but on one side.
4. Horizontal on the spur: For endoscopic spurectomy

22. The incision and Approach
Insert the nasal speculum into the nose and gently
retract the slightly opened speculum revealing
the caudal septal cartilage
No 15 blade is then used to incise mucosa down to
and through the perichondrium on the concave side

23. 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 is made, the medial crura are seperated and the caudal
septum is then identified
Tip support is significantly weakened with this
open dissection technique, reserved for open
approach to septal perforation repair or in
complex cases

24. Plane identification and mucoperichondrial flap elevation
Identification of the proper plane- 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

25. 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 speculum is used as the dissection proceeds posteriorly.

26. When the bony osteocartiliginous junction is reached, this junction
is disarticulated to gain access to the opposite side of the bony septum
The mucosal flap is raised carefully 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-cartilginous junction at the L- strut is left undisturbed if possible

27. Managing the spur
Raising the flap over a septal spur can be challenging
The Mucoperichondrial flap is raised over the quadrilateral
cartilage and the bony septum; this constitutes the anterior channel
over the spur
Then another subperiosteal tunnel is raised posterior to the septal
spur which constitutes the posterior channel
Connecting the two tunnels directly helps to avoid mucosal flaps
The dissection may be eased with the use of the sharper spade
end of the cottle elevator

28. The risk of membrane fenestration is greatest in the area of a spur
To mobilize the bony deviation or spur, becker septal scissor are used to make cuts
in the bony septum above and below the deviated septal segment or spur
To prevent cribiform plate injury, the superior bony septum is never manipulated
without first performing a superior septal incison or cut
Even then, any posterior septal removal is done within one rotational plane

29. Removal of the freed segment with a nonbiting forceps completes
the resection using wide-mouthed Watson-Williams forceps

30. SEPTOPLASTY TECHNIQUES
• CUTTING TECHNIQUES
• GRAFTING TECHNIQUES
• SUTURING TECHNIQUES
• RELOCATING TECHNIQUES

31. CUTTING TECHNIQUES
• Scoring→ septal cartilage→ concave →straight→eliminating deviation
• Under-scoring & over-scoring →unsatisfactory results
• S -shaped→ scoring in both concave sides
• Caudal septal deviation-swinging door technique

32. Grafting technique
• Both septal cartilage & septal bone
• Harvesting → perpendicular plate of ethmoid →thinned → graft→ perforated
→splinted concave side of the septum
• Suture →secure the graft to the septum

33. Suturing technique
• Mattress suture can be used
• Septum is first scored→ pliable→ shaped kept in shape→ fine
sutures
• Entrance & exit sutures are placed on convex side

34. Relocating technique
• These techniques are used when the septum is dislocated off the midline and it
only requires reinsertion onto the maxillary crest
• The septum needs to be secured in its midline position
• Achieved by suturing 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

35. SPECIAL SEPTOPLASTY CONSIDERATIONS
1. Endoscopic septoplasty
• Used to improve visualization particularly of more cephalic septal deformities
• Allows minimal access dissection to reach isolated deviated parts of the septum
(more relevant in revision cases).
• Endoscopic septoplasty can be used concomitantly along with sinus surgery
• It is also an effective teaching tool

36. Extracorporeal septoplasty
• In cases of a severely fractured and deformed septum
• In this method, the septum (both cartilaginous and the bony segment) is excised in
one piece as intact as possible
• This requires detachment of the cartilaginous septum from upper lateral cartilages
and its attachment to the maxillary crest posteriorly
• The septum is then measured and a template is made to represent the new
septum.

37. 1. Re-orientation:
The new L-strut is harvested from a straight section of the excised septum and it is reinserted in place
2. Reconstruction:
The septum is reconstructed by a variety of techniques and then reinserted in its
place
In cases of fractured septum, the fracture line is cut through or weakened to straighten the septum and
then the septum is splinted against a graft
In cases where the septum is broken into many pieces, the segments of septum are splinted against a
sheet of thinned down perpendicular plate of ethmoid or a PDS sheet (like a jigsaw puzzle)
A fine absorbable or non-absorbable suture (e.g. 5x0 PDSR) is used to secure the pieces of septum to
the ethmoid bone graft or the PDS sheet.

38. 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

39. 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
After the nasal packs are removed, a thrice-daily regimen of saline flushing of the nose
is initiated
Gentle suctioning on postoperative days 5 through day 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 sternous exercise is
discouraged for a total of 5 weeks

40. Complications of septoplasty
Persistence in the subjective complaint of nasal obstruction(Most common)
Sepal hematoma
Septal perforations
Nasal shape change
Synechiae
Excessive bleeding
CSF rhinorrhea
Wound infection
Septal Abscess
Toxic shock syndrome
Sensory changes- Anosmia or dental anaesthesia

41. SUBMUCOSAL RESECTION
In this technique, the L-strut is not addressed
Generally done in adults
Consists of elevating mucoperichondrial and mucoperiosteal flap on either side of the
septum, removing the deflected parts of bony and cartiliginous septum and then
repositioning the flaps

42. Indications
1. Deviated nasal septum (DNS) causing symptoms of nasal obstruction and recurrent
headaches.
2. DNS causing obstruction to ventilation of paranasal sinuses and middle ear, resulting
in recurrent sinusitis and otitis media.
3. Recurrent epistaxis from septal spur.
4. As a part of septorhinoplasty for cosmetic correction of external nasal deformities.
5. As a preliminary step in hypophysectomy (trans-septal trans-sphenoidal approach)
or vidian neurectomy(trans-septal approach)

43. CONTRAINDICATIONS
1. Patients below 17 years of age. In such cases, a conservative surgery (septoplasty)
should be done.
2. Acute episode of respiratory infection.
3. Bleeding diathesis.
4. Untreated diabetes or hypertension

44. SMR Steps
Infiltration: Subperichondrial infiltration with 2% xylocaine with adrenaline
Incision: Killian’s incision- curvilinear incision 2-3 mm behind the anterior end of septal
cartilage
Elevation of flaps
Incision of the cartilage
Elevation of opposite mucoperichondrial and mucoperisoteal flap

45. Removal of cartilage and bone
Cartilage can be removed with ballinger swivel knife or Luc’s forceps
Bony spur removed using gouze and hammer
Preserve a strip of 1 cm wide cartilage along the dorsal and caudal borders(L-
struts)
Nasal Packing

46. References
• Scott-Brown's Otorhinolaryngology and Head and Neck Surgery, Eighth
Edition
• Scott-Brown's Otorhinolaryngology and Head and Neck Surgery, Seventh
Edition
• Cummings otorhinolarngology Head and Neck Surgery
• Disease of ear nose throat and head and neck surgery Dhingra 7th
edition

47. Next presentation
Topic: Neck Dissection
Presenter: Dr Satish Kumar Ray
Friday

48. Thank You!!!