Septoplasty: Basic and Advanced Techniques

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Key points

  • Nasal septoplasty is one of the most common procedures in otolaryngology owing to the high prevalence of nasal obstruction from septal deviation.

  • Traditional septoplasty is often inadequate in addressing nasal obstruction owing to anterior septal deviation, even when performed in conjunction with techniques to address nasal valve stenosis.

  • Extracorporeal resection allows for correction of severe anterocaudal septal deviation but carries a risk of notching at the rhinion.

  • Anterior septal

Septal anatomy

A thorough understanding of the anatomy and function of the nasal septum and its surrounding structures is critical for surgical success. The nasal septum sits in the sagittal plane, extending from the maxillary crest inferiorly to the skull base superiorly and from the nasal tip anteriorly to the nasopharynx posteriorly and divides the nose into 2 nasal cavities.

The nasal septum is composed of both bony and cartilaginous components. Bony components include the maxillary crest, whose anterior

Surgical Indications

The most common indication for septoplasty is septal deviation with correlated symptomatic nasal obstruction. Note that a deviated septum alone (ie, without symptomatic obstruction) is not an indication for septoplasty. Other indications include improved access for endoscopic sinus surgery, lead point headaches, and source of graft (cartilage, bone, or mucosal) for patients undergoing skull base surgery.4

Preoperative Workup

A thorough preoperative workup is essential for maximizing the potential for benefit and

Surgical technique

Septoplasty can be performed either with a headlight and nasal speculum, or endoscopically. There are advantages and disadvantages to both techniques, but both have been shown to be successful means by which to correct septal deviation.13 Regardless of which approach is selected, the same basic surgical technique applies for traditional septoplasty, that is, that involving mild to moderate deviation of the mid or posterior septum.

Anterior septal deviation

In cases of mild to moderate mid or posterior septal deviation, the standard septoplasty approach described provides significant benefit in nasal obstruction for most patients.14 However, deviation of the severely deviated septum, and specifically deviation of the anterocaudal nasal septum, poses unique anatomic and structural challenges that make repair far more challenging.15, 16, 17, 18, 19 Anterocaudal septal deviation can be the result of congenital, traumatic, or iatrogenic insults. This

Extracorporeal resection

As its name implies, the guiding principal of extracorporeal resection is removal of the entire nasal septum to correct severe deviation. Although this has been described as an endoscopic procedure, today this is typically addressed via an external rhinoplasty approach. The procedure has been extensively described by Gubisch.24 As detailed by Gubisch, this procedure can be described in 3 distinct stages, the first of which is exposure and removal of the native septum. The first stage begins

Anterior septal reconstruction

In light of the aesthetic deformity and difficulty with keystone reconstruction associated with extracorporeal resection, Most25 has described a modified form of extracorporeal resection, called ASR. ASR follows the same general principles as standard extracorporeal resection with the key distinction that in ASR, a dorsal strut is preserved (Fig. 4). This allows for the ability to correct severe and anterocaudal septal deviation, unlike with standard septoplasty, while minimizing the risks of

Patient outcomes in anterior septal reconstruction

In the senior author’s original description of 12 patients, nasal obstructive symptoms were reduced significantly as measured by NOSE scores. Subsequently, Surowitz and colleagues26 analyzed 77 patients who underwent ASR. Septal cartilage was used for the ASR graft in 60 cases, autologous rib in 7 cases, and homologous irradiated rib in 10 cases. There was a statistically significant difference between NOSE scores, both between the preoperative mean (68.2) and early postoperative mean (21.1)

Summary

Nasal septal deviation is a prevalent problem that can have significant quality of life ramifications in affected individuals. Septoplasty is a commonly performed procedure that provides qualitative and quantitative benefit to many individuals who suffer from nasal obstruction owing to septal deviation. Although a standard, basic technique is often adequate for individuals with mild to moderate mid to posterior septal deviation, unique challenges arise with caudal septal deviation, especially

Acknowledgments

Medical illustrations by Christine Gralapp, MA, CMI.

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