Continuing Education Activity
Nasal septoplasty is one of the most commonly performed procedures within ENT and plastic surgery. Indication for functional (as opposed to purely aesthetic) surgery is usually septal deviation resulting in significant and symptomatic nasal airway obstruction. This activity outlines and describes comprehensive steps in performing a septoplasty procedure. It also highlights the interprofessional team's role in managing patients who undergo this procedure, ensuring appropriate pre-operative assessment and investigation is undertaken.
- Outline the indications and contraindications for performing septoplasty procedures.
- Describe the pre-operative work-up of patients being considered for septoplasty.
- Summarize the surgical equipment and healthcare team required for septoplasty procedures.
- Describe and explain the technical operative steps involved in the procedure.
Nasal septoplasty is one of the most commonly performed procedures within ENT and plastic surgery. Indication for functional (as opposed to purely aesthetic) surgery is usually septal deviation resulting in significant and symptomatic nasal airway obstruction. Many surgical techniques exist and can be performed according to surgeon preference and expertise; these include endonasal, endoscopic and open procedures. Septoplasty can also be performed alongside or in addition to rhinoplasty, turbinoplasty, or as part of functional endoscopic sinus surgery for access. Operative recovery is usually a few weeks, and serious complications are rare. Appropriate patients must be listed for surgery to maximize patient outcomes.
Anatomy and Physiology
Critical to performing a successful septoplasty is a thorough understanding of the anatomy of the nose, specifically the nasal septum. The septum is the main supporting structure of the nose, providing support to the dorsum of the nose, the columella, and the nasal tip. It also separates the nasal cavity, creating two distinct nasal passages that enable warming, humification, and air turbulent flow. Deviation of the septum can reduce the cross-sectional area of the nasal valve, which subsequently leads to airway obstruction. This can create symptoms of nasal blockage and, in rare circumstances, worsen the symptoms of obstructive sleep apnea. Bony spurs resulting from a deviated nasal septum may result in epistaxis, headaches, and facial pain.
The septum has three main components: membranous, cartilaginous, and bony. The membranous septum is made up of fibrous tissue and forms the most anterior portion between the lower lateral alar cartilages. As the name suggests, the quadrangular cartilage is quadrangular in shape and sits posterior to this membranous section. It attaches to the maxillary crest inferiorly, the upper and lower lateral cartilages anteriorly, and the bony septum posteriorly. The bony septum is made up of the vomer, which sits inferior-posterior to the cartilage, and the perpendicular plate of the ethmoid (PPE) sits superior-posterior. The ethmoid bone is continuous with the skull base and sphenoid bone. The nasal bone sits on the dorsal aspect of the nose, superior to the perpendicular plate.
The two surgically relevant areas of fixation of the septum are at the junction with the anterior nasal spine of the maxilla and the ‘keystone area.’ The keystone area is located at the confluence between the nasal bones, quadrangular cartilage, upper lateral cartilages, and PPE; it is a pivotal area for stability and structure and must be considered in surgical handling during septoplasty.
These cartilaginous and bony components are covered with mucoperichondrium and mucoperiosteum, which provides innervation and a rich vascular supply. This enables the mucosa to swell and shrink, allowing warming and humidification of air through the nasal cavity. The surface mucosa is mainly made up of pseudostratified respiratory epithelium. The olfactory epithelium is located more superiorly near the olfactory region of the nose.
The blood supply to the nasal septum is via a collection of arteries derived from the internal and external carotid arteries. The internal carotid artery gives rise to the anterior and posterior ethmoidal arteries (via the ophthalmic artery), which supply the superior aspect of the septum. The external carotid gives rise to the facial and maxillary arteries, the terminal branches providing the remaining vascular supply—the facial artery branches to form the superior labial artery, supplying the anterior aspect. The maxillary artery branches form the greater palatine and sphenopalatine artery, which supplies the inferior and posterior septum. They anastomose anteriorly to form Keisselbach’s plexus, otherwise known as Little’s area and the commonest site of epistaxis.
The ophthalmic (V1) and maxillary (V2) branches of the trigeminal (V) cranial nerve innervate the internal and external nose. Specifically, concerning the septum, the nasociliary branch of the ophthalmic nerve (VI) gives rise to the anterior and posterior ethmoid nerves, which supply the anterior-superior and posterior-superior aspects of the septum, respectively. The nasopalatine branch of the maxillary nerve (VII) supplies the posteroinferior aspect of the septum. The superior alveolar nerve, also a branch of the maxillary nerve, supplies the anterior septum. The olfactory nerve (I) is responsible for providing sensory information from the olfactory epithelium to the olfactory bulb.
The main indication for performing a septoplasty is a nasal septal deformity. This is usually a deviation of the cartilaginous or bony parts of the septum into the right or left nasal passage, causing the cross-sectional area to become reduced, hindering airflow and causing a sensation of nasal blockage. Patients may particularly complain of symptoms of obstruction on exertion or while exercising. The most common cause of the deviation is trauma. Patients must be symptomatic with nasal blockage to warrant functional surgery.
Several scoring systems are available to grade nasal obstructive symptoms. The Nasal Obstruction Symptom Evaluation (NOSE) Scale is a reliable scale used to evaluate the degree of obstruction. Those with low scores are unlikely to benefit from surgery. It is important to take a thorough history to establish whether concomitant factors may contribute or cause obstruction, such as trauma, rhinosinusitis, allergies, vasculitis, illicit drug use, chronic use of decongestants, autoimmune disease, or malignancy. In these cases, adequate medical therapy (e.g., intranasal corticosteroids for chronic rhinosinusitis) should be offered in the first instance.
Other indications for septoplasty include recurrent epistaxis, obstructive sleep apnea, sinusitis, and facial pain and/or headaches due to septal spurs. Septoplasty may also be necessary in conjunction with endoscopic sinus, skull, or orbital surgery, to provide better surgical access to necessary structures.
There are several contraindications to performing surgery. Firstly, concurrent diseases such as rhinosinusitis or vasculitis, where adequate medical therapy has not been trialed. This would give a false sense of optimism that the operation would improve symptoms when, in fact, it may have no effect or even worsen the disease.
Current recreational drug use, particularly intranasal cocaine, is highly inadvisable. The vasoconstrictive and mucosal damaging effects of cocaine can prompt complications such as inadequate cartilage correction, delayed healing, septal perforation, and dorsal collapse. It is best practice to ensure patients have been abstinent for at least 6 to 12 months before operating, and toxicology screening may be necessary. Similar precautions should be taken with patients who display signs of rhinitis medicamentosa. Vasoconstrictive decongestant nasal sprays should again be avoided for a significant period pre- and post-operatively.
Careful consideration of patients who have unrealistic expectations of aesthetic or functional septoplasty outcomes should be made. This is even more applicable to those undergoing additional rhinoplasty. Questions should be asked to ascertain whether expectations are achievable as this will determine post-operative patient-related outcome measures. Similarly, those with septal deviation and deformity, but limited functional symptoms may have limited benefit from surgery.
Patient co-morbidities, functional status (ASA grade), and extremes of age all need to be considered to assess whether they may be fit for a general anesthetic and whether they would be able to tolerate the post-operative recovery period.
A standard septoplasty set usually includes the following. Note that surgeons may only use a fraction of these instruments during the operation, depending on their technique.
- Hartmann nasal speculum
- Cottle nasal speculum
- Killian nasal speculum (3 sizes)
- Killian retractor
- Hills elevator
- Cottle curved scissors
- Blakesley nasal forceps
- Takahashi nasal forceps
- Blakesley-Wilde nasal forceps
- Lubet-Barbon nasal dressing forceps
- Ferguson suction tube
- Bipolar diathermy forceps
- Adson-Brown tissue forceps
- Jansen nasal dressing forceps
- Cottle lower lateral forceps
- Cotton applicator
- McKenty raspatory
- Freer chisel
- Freer elevator
- Cottle chisel
- Cottle metal mallet
- Backhaus towel forceps
- Needle holder
- Medicine cup
- Frazier suction tube
- Hopkins rod, light source, and stack (if endoscopic)
ENT surgeons usually carry out septoplasty procedures. Among the specialty, simple septoplasties are considered fairly non-specialist and can be performed by most ENT surgeons. Revision surgery or more complex procedures, with or without rhinoplasty, may be performed by rhinology specialists. Some plastic surgeons also perform septoplasties as part of their practice. Additional personnel required to complete the operation includes an anesthetist, a scrub nurse, an operating department practitioner (ODP), theatre and recovery nurses, and coordinators.
A full history detailing the nature and extent of nasal symptoms should be obtained. Symptoms of other sinonasal or systemic pathology, including allergies, should be explored. Scoring systems such as the NOSE Scale can be used to grade nasal obstructive symptoms. A detailed drug history with a particular focus on intranasal decongestants and corticosteroids in addition to any recreational drug use should be obtained. If the patient smokes, they should be advised to stop or cut down on their tobacco use. It is useful to note if the patient has had previous nasal or sinus surgery, issues with previous anesthetics, or bleeding conditions.
Patients should be thoroughly examined in the outpatient clinic. A full head and neck examination should be carried out, followed by anterior rhinoscopy with a nasal speculum. Flexible nasendoscopy can be carried out to look for signs of sinonasal disease or masses in the posterior nasal space. When evaluating the nasal septum, the surgeon should look at the quality of the mucosa (signs of inflammation) and the size and nature of the turbinates, particularly the inferior turbinate. If there is poor access due to overly large turbinates, a turbinoplasty may also be indicated. The septum should be palpated to evaluate the size, location, and nature of the deviation, noting specifically whether this seems cartilaginous or bony and whether there is any septal perforation, dislocation, or bony spurs. External examination, noting any additional deformity and degree of caudal tip support, should be made. Lastly, Cottle’s maneuver should be performed to assess internal valve stenosis. A thorough examination will assist in the decision process for whether surgery is appropriate, the level of difficulty, and what approach and technique would be most suited for this patient.
- The positioning of the patient with the head ring and head tilted slightly towards the surgeon, standard drapes.
- Trimming of prominent nasal hairs
- Some surgeons prefer to decongest the nose with xylometazoline or Moffatt’s solution.
- Local anesthetic infiltration bilaterally in the sub-mucoperichondrial plane with 1% lidocaine with adrenaline (1:100,000) until mucosa is well blanched. This assists in hydro-dissection of the planes in addition to analgesia and hemostasis
Raising Mucoperichondrial Flaps
- A Killian’s nasal speculum is used to expose the caudal edge of the septum. An incision is made using a 15-blade to this caudal edge down to cartilage. Typically a hemi-transfixion (vertical incision at the very caudal edge) or Killian’s incision (vertical incision slightly more posterior) is used.
- Dissecting scissors and Freer or Cottle’s elevators are then used to create a sub-mucoperichondrial plane and dissect posteriorly to reveal the quadrangular cartilage, PPE, and vomer bones. It is imperative to achieve the correct plane; this is usually characterized by a pearly white/blue color seen when the cartilage is exposed. Care needs to be taken not to perforate the mucosa, especially if dissection over bony spurs or deviations is needed. A second flap on the contralateral side is then raised through the same incision. If a mucosal perforation has occurred on one side, extreme care needs to be taken not to perforate the contralateral side; bilateral perforations could lead to a septal perforation post-operatively due to lack of vascular supply. As the surgeon reaches further posteriorly, longer nasal speculums will be required to obtain good visualization.
Septal Deviation Correction
- Evaluation of the location, direction, and nature (cartilaginous/bony) of the deformity is made.
- A variety of instruments can be used to incise the deviated piece of the septum, and sometimes these are used in combination. A blade, a Freer elevator, Jansen-Middleton forceps, or Blakesley forceps are used to remove a piece of cartilage. To maintain the nasal dorsum and tip stability, an ‘L-strut’ shape of quadrangular cartilage is preserved (dorsal and caudal edges); the posterior aspect of the cartilage is, therefore, often the area that is removed. A twisting movement is often employed to remove sections of cartilage or bone; care must be taken not to twist too forcefully outside of the anterior-posterior axis as this could cause a fracture of the cribriform plate or disruption of the keystone area.
- Removed cartilage should be saved. Pieces of native cartilage can be reshaped and placed inside the septal cavity to straighten other areas.
- The mucopericondrial flaps are laid back into position against the septum. Interrupted sutures using absorbable suture material (e.g., Vicryl) are used to approximate the skin of the flap and the columellar anteriorly.
- Mattress sutures are often made through-and-through the septum anterior to posterior using a straight needle to close any dead space and reapproximate the flaps.
- Silastic splints are sometimes required. These are cut to size, placed adjacent to the septum, and sutured with silk sutures for easy removal in the outpatient clinic. The splints aim to prevent adhesions to the turbinates if these are hypertrophied or if turbinoplasties have also been performed.
- An antibiotic cream can be applied intranasally.
- Patients are usually able to be discharged the same day.
- Naseptin cream and oral analgesia are prescribed.
- The patient will need to be seen in approximately 2 weeks for post-operative assessment and removal of splints if used.
The various steps and techniques used are similar to the traditional endonasal method. Rather than using a nasal speculum and headlight, a 0 degrees endoscope is utilized to visualize the nasal structures and septum. The endoscope can be placed between mucosal flaps to ensure adequate resection is achieved. This method may more commonly be used in conjunction with functional endoscopic sinus surgery (FESS), where endoscopic techniques will already be needed.
Endoscopic techniques enable enhanced visualization and magnification of the anatomy. This is particularly helpful when teaching more junior surgeons. Endonasal style procedures are notoriously difficult to observe, which makes training challenging. In revision cases, where there is scarring or adhesions, it can also help determine the correct planes more closely.
However, endoscopic septoplasties are seen to be technically more challenging than endonasal methods. It has been described that the learning curve, even for senior surgeons trained in endonasal and FESS surgery, may take about 60 procedures before achieving satisfactory operative times and a decreased rate of operative complications such as mucosal perforations. Anterior defects may be challenging to correct endoscopically as the surgeon cannot easily stabilize the endoscope and may have to use a ‘free-hand’ technique.
Complex septal deformities in all three areas (quadrangular cartilage, PPE, and vomer) or previous comminuted fractures may make traditional techniques very challenging or impossible. In this case, ‘extracorporeal’ methods may be needed where the whole septal cartilage is removed, the deviation corrected, and then replaced. This may be performed as an open procedure through a rhinoplasty incision (an inverted V shape columellar incision), as part of a septorhinoplasty, or alternatively, it can be performed as a closed procedure with the extension of a hemi-transfixion incision.
Once the septum has been removed, several techniques have been described to attempt to straighten it. These include making partial-thickness incisions on the concave side of the deviation, incising fracture lines and re-suturing component parts together, or drilling/filing sections of the septal cartilage. An additional technique involves suturing excised septal cartilage to a polydioxanone scaffolding plate. The cartilage may be rotated and replaced in a different orientation if this provides superior structural support. It must then be reimplanted and sutured to the lateral cartilages and anterior nasal spine.
In cases where there is minimal cartilaginous septum remaining (due to previous surgery or necrosis), a neoseptum may be made from fragments of existing septal cartilage or autologous harvesting, e.g., costal cartilage. Homologous grafts (homologous costal cartilage harvested from cadaveric donors) can also be used.
Several complications may occur due to septoplasty procedures; these must be fully described and explained to the patient during informed consent. The most common is excessive bleeding; some oozing is expected, but more extensive bleeding can be managed by nasal packing and may require cautery in rare circumstances. Septal hematomas can occur where bleeding occurs beneath the mucoperichondrium. This will need to be drained in the theatre to prevent a septal perforation. Perforations can also occur due to bilateral mucosal perforations intra-operatively, causing reduced vascular supply; if a perforation causes dorsal collapse, then a saddle nose deformity may develop, and this will inevitably require revision surgery.
Infection, blocked nose, and prolonged healing can occur in a proportion of patients. This can be treated with antibiotics, and the vast majority of patients will have a full recovery within a few weeks. Hyposmia has been described in some patients (more frequently with concurrent turbinoplasty procedures; this usually resolves within 6 months. Intranasal adhesions can occur, but the use of silastic splints minimizes the risk of this. Lastly, patients may experience numbness to the upper teeth or lips; this is usually short-lived, and sensation returns within a few months.
Septoplasty is one of the most performed ENT procedures. Systematic reviews have revealed that long-term patient outcomes are favorable for many patients with septal deviation-related obstructive symptoms. However, despite this, a significant proportion of patients experience significant obstructive symptoms post-surgery, and satisfaction rates can be extremely variable (50% to 100% satisfaction).
Post-operative outcomes are commonly evaluated by patient satisfaction, quality of life outcomes, and symptom improvement. It is difficult to evaluate symptom improvement, given it is often very subjective, and objective measurements do not always align with patient perception. Some studies have shown a decline in long-term outcomes for patients. One study showed that 26% of patients had no nasal obstruction after 9 years, by comparison to 51% 9 months post-operatively. Another study reported that 53% of patients were symptom-free at 6 months post-operatively, but only 18% remained symptom-free at 34 to 70 months. This may demonstrate that the effects of surgery are short-lived for some patients.
Evaluation of candidates for surgery is done on a clinical basis, and it is not entirely clear in the literature what prognostic factors determine successful postoperative outcomes. A combination of objective and subjective measures to identify appropriate patients may help improve outcomes in the future.
In countries such as the UK, which operate on a state-funded healthcare system, it is imperative to demonstrate that such operations have a significant impact on the quality of life and symptom burden to justify funding. Patients must be evaluated clinically, and evidence-based decisions for surgery in those most likely to benefit favorably post-operatively.
Enhancing Healthcare Team Outcomes
Managing patients who require septoplasty pre-, intra-, and post-operatively requires multidisciplinary team working. Outpatient assessment in ENT clinics requires a team of ENT surgeons, nurses, and administrative staff. Intra-operative staff (as aforementioned in the ‘Personnel’ section) are imperative to carry out the operation smoothly and successfully, minimizing complications.