Septoplasty—Classic and Endoscopic

The most common structural cause of persistent nasal obstruction unresponsive to nasal decongestants or medical therapy is a deformity of the nasal septum.

Septal deformities may be cartilaginous, bony, or both, with tilts to the septum, curves, spurs, twists, angulations, telescoping segments, or any combination thereof. A septal deviation can be observed within a nasal framework that is straight externally, crooked, twisted, or collapsed and with compromise at the internal nasal valve, the external nasal valve, both, or neither. One must realize, therefore, that there is no single operation that will remedy all septal deviations and that some may in fact require application of more complex functional rhinoplasty techniques. In all cases, astute evaluation and flexibility in technique are the essential foundation for improved outcomes.

In this chapter we endeavor to provide guidance for the more basic or routine deformities and correction via classic (endonasal) and endoscopic approaches. The techniques of endoscopic septoplasty can be useful in addition to classical endonasal techniques, especially in patients who also require concomitant endoscopic sinus surgery. Endoscopic septoplasty can provide excellent visualization of the anatomy and can be successfully incorporated into the existing armamentarium of the endoscopic sinus surgeon. This chapter also provides recommendations on how to identify deformities that warrant more advanced surgical intervention to minimize failure and maximize success rates.

Key Operative Learning Points

1.
Elevation of the mucosal flaps in the correct plane is crucial for performing the procedure with the classical endonasal or endoscopic technique.
2.
Careful dissection through grooves and around angles or spurs will minimize the risk of mucosal tears and possible septal perforation. To whatever extent is possible, mucosal tears should be repaired when quilting the septal flaps at the end of the procedure.
3.
Preoperatively and intraoperatively, attention should be focused specifically at the common sites of failure: curvatures within the dorsal septal strut and caudal septal deviations. Deviations within these areas can be subtle but nonetheless have a significant impact on airflow secondary to high resistance in these areas (the internal and external nasal valves).
4.
With the endoscopic approach:
- a.
  Once the flap is elevated appropriately, it is helpful to keep an instrument or scope in the plane of dissection to facilitate visualization and limit manipulation of the flap.
- b.
  The axilla of the middle turbinate should be visualized bilaterally once the deviation has been corrected to allow for appropriate access, especially if frontal sinus surgery is necessary.

Preoperative Period

History

1.
History of present illness
- a.
  Most troublesome symptoms: This helps in direct counseling and expectations of what surgery can and cannot achieve.
- b.
  Duration of obstruction
- c.
  Laterality, if any: Most often, symptoms will be worse on one side, but S -shaped septal deflections can compromise both sides of the nasal airway.
- d.
  Specific symptoms: Nasal obstruction, hyposmia, epistaxis, facial pressure/pain, nasal discharge/postnasal drip
- e.
  Use of any topical medications (e.g., nasal steroid sprays) and response
- f.
  Trial and effect of nasal dilating strips
- g.
  History of environmental allergy
2.
Past medical history
- a.
  Prior nasal surgery, cosmetic or functional, increases the index of suspicion for loss of volume or support of upper or lower lateral cartilages and implies greater scarring between previously elevated mucosal flaps and therefore higher risk of mucosal tears.
- b.
  Prior nasal trauma: Depending on physical findings, prior trauma may require application of functional septorhinoplasty techniques for optimal correction of the nasal airway.
- c.
  Medical illnesses
- d.
  Medications:
  - 1)
    Antiplatelet drugs
  - 2)
    Herbal products
  - 3)
    Alcohol
  - 4)
    Smoking cigarettes

Physical Examination

1.
Observation: Breathing at rest and with moderately forceful inspiration to assess stability of nasal sidewall for static or dynamic collapse
2.
Anterior rhinoscopy to enable description of the septal deflection (tilt, curves, angulation, spurs, grooves, location). This should include critical evaluation of the position of the caudal septum and patency/obstruction of the angle of the internal valve.
3.
Palpation of caudal septum to clarify position, orientation with respect to dorsal strut, strength, and angulation if any
4.
Nasal endoscopy to evaluate for other sources of obstruction (e.g., sinonasal mass, polyposis, adenoid hypertrophy) and document pre-existing septal perforation if present. An endoscopic evaluation involves three “passes” of the endoscope:
- a.
  Along the floor of the nose to inspect the inferior turbinate, inferior meatus, nasolacrimal duct, and nasopharynx (fossa of Rosenmuller and Eustachian tube orifice)
- b.
  Toward the middle turbinate, examining the middle meatus, ethmoid bulla, uncinate and lateral nasal wall, sphenoethmoidal recess, superior turbinate, and sphenoid os
- c.
  Superiorly toward the olfactory cleft (often with a 30-degree endoscope)

Overall, the physical examination should enable the surgeon to describe the cartilaginous and bony septal deformity in detail, with particular note made of deviations of the dorsal or caudal septum, obstruction impacting the internal or external nasal valve, and/or instability of the nasal sidewall.

Upon completion of the physical examination, the surgeon should be able to recognize the more complex septal deformity for which “routine” septoplasty might prove to be inadequate. This is an essential part of minimizing failure or revision rates. Circumstances that present a higher risk for surgical failure, for which a more involved operation (functional septorhinoplasty) might be more appropriate, are more readily identifiable at the completion of the examination by routinely asking the following questions:

Is there a nasal valve problem?
Is there a dorsal septal deviation?
Is there a caudal septal deviation?
Are there complex deformities in regions that provide critical support to the nasal dorsum or tip that cannot be treated with conventional excisional techniques and require reconstruction or reimplantation of cartilage?

Imaging

Imaging is not routinely required in the evaluation of the deviated septum unless one is concerned about alternative sources of nasal obstruction or evaluating for concomitant sinus disease, in which case a dedicated maxillofacial computed tomography (CT) scan would be warranted.

Indications

1.
Symptomatic nasal airway obstruction with a deviated nasal septum
2.
Access to paranasal sinuses for endoscopic sinus surgery
3.
Sphenoid sinus/pituitary access
4.
Management of epistaxis posterior to a septal deflection

Contraindications

1.
Unfit for general anesthesia (medical comorbidities)
2.
Uncorrectable coagulopathy or use of anticoagulants that cannot be held through the perioperative period

Preoperative Preparation

1.
Discontinue antiplatelet drugs.
2.
Coagulation profile if there is a history of excessive bleeding
3.
Medical clearance if necessary
4.
Preoperative counseling regarding the procedure, risks, and complications

Operative Period

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Introduction