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Septoplasty For Nasal Obstruction Indications and Techniques

Submitted by etannenbaum on Thu, 11/02/2023 - 16:50
3. Carter, H.V. File: Gray814.png. Wikimedia Commons. 1918. Accessed December 3, 2023. commons.wikimedia.org/wiki/File:Gray514.png
4. Carter, H.V. File: Gray854.png. Wikimedia Commons. 1918. Accessed December 3, 2023. commons.wikimedia.org/wiki/File:Gray854.png.

See also:  Open Septorhinoplasty - Surgical Demonstration (rhinoplasty)

April 2024 Created by Eddie Tannenbaum BA (University of Iowa School of Medicine) and Shaun Edalati BS (Mount Sinai School of Medicine) edited Jarrett Walsh MD and Henry  Hoffman MD

Background

  1. Introduction

    1. Nasal obstruction is one of the most common complaints and may be the primary presenting symptom of various common conditions, such as septal deviation, rhinitis, sinusitis, and nasal trauma (Alessandri‐Bonetti et al., 2023; Bhattacharyya, 2023). It is defined as the subjective sensation of inadequate airflow through the nose (Alessandri‐Bonetti et al., 2023). The etiology of nasal obstruction can be broadly defined as either mucosal or structural (Bhattacharyya, 2023). For example, rhinitis and nasal polyps are considered mucosal causes whereas septal deviations and tumors are classified as structural (Bhattacharyya, 2023). Although most individuals with nasal septal deviations are asymptomatic, the condition is quite common with a prevalence of up to 90% (Sedaghat & Bleier, 2023). The primary treatment for nasal obstruction caused by septal deviation is septoplasty, which can involve a few different surgical procedures including reshaping septal cartilage and resection of bone and cartilage (Bhattacharyya, 2023; Haffey et al., 2012). The origins of septoplasty can be traced back to Egypt in 3500 BC (Haffey et al., 2012). In the modern era, septoplasty is the most common ENT procedure in adults (van Egmond et al., 2018).

  2. Anatomy

    1. The nasal septum forms the medial wall of each nasal cavity and is composed of bone and cartilage. The anterosuperior bony component consists of the perpendicular plate of the ethmoid, which attaches to the cribriform plate above (Standring & Gray, 2021). Rough manipulation of the perpendicular plate can result in skull base fracture, leakage of cerebrospinal fluid, and meningitis (Sedaghat & Bleier, 2023). Inferior to the ethmoid, the septum is composed of the vomer. In addition, the nasal bones and spine of the frontal bones as well as the nasal crests of the maxilla and palatine bones make minor contributions to the septum (Standring & Gray, 2021).
    2. 3. Carter, H.V. File: Gray814.png. Wikimedia Commons. 1918. Accessed December 3, 2023. commons.wikimedia.org/wiki/File:Gray514.png
    3. The anterior component of the septum consists of the quadrangular cartilage, which articulates with the maxillary crest anteriorly and the vomer posteriorly (Sedaghat & Bleier, 2023). The cartilaginous part anterior to the nasal spine of the maxillary bones is necessary for tip support and excision can result in columellar retraction (Standring & Gray, 2021).
    4. Periosteum and perichondrium cover the bone and cartilage of the septum, providing blood supply. More superficially, the septum is covered in respiratory mucosa (Sedaghat & Bleier, 2023). The periosteum of the maxillary crest is distinct from the perichondrium of the quadrangular cartilage and periosteum of the vomer. As such, the fibrous attachments must be cut to join the subperichondrial and subperiosteal dissection planes over the quadrangular cartilage or vomer with the subperiosteal plane over the maxillary crest (Sedaghat & Bleier, 2023).
    5. The septum, inferior turbinate, upper lateral cartilage, and floor of the piriform aperture form the narrowest section of the nasal airway, the internal nasal valve (Sedaghat & Bleier, 2023). If septal deviation occurs here, there is a high likelihood for symptomatic obstruction.
    6. Two important points of articulation of the septum include the “keystone area” and the junction with the anterior nasal spine of the maxilla (Watters et al., 2022). Located deep to the rhinion at the union of the perpendicular plate of the ethmoid, quadrangular cartilage, upper lateral cartilage, and nasal bones, the keystone area is vital for stability of the nasal dorsum (Watters et al., 2022).
    7. Both the internal (ICA) and external carotid (ECA) arteries supply the nasal septum. The ECA supplies the anterior septum via the superior labial artery which branches from the facial artery. In addition, the ECA gives rise to the maxillary artery that branches to form the greater palatine and sphenopalatine arteries, supplying the posteroinferior septum. The ICA supplies the superior septum via the anterior and posterior ethmoidal arteries, which branch from the ophthalmic artery. The sphenopalatine, greater palatine, superior labial, posterior ethmoidal, and anterior ethmoidal arteries anastomose to form Kiesselbach’s plexus (Watters et al., 2022).
    8. 4. Carter, H.V. File: Gray854.png. Wikimedia Commons. 1918. Accessed December 3, 2023. commons.wikimedia.org/wiki/File:Gray854.png.
    9. (Carter, 1918 with permission – Wiki Commons)
    10. The trigeminal nerve (CN V), through the ophthalmic (CN V1) and maxillary (CN V2) branches, provides general sensory innervation to the nasal septum (Watters et al., 2022). Primarily, the septum is innervated by the anterior and posterior ethmoidal nerves, which arise from the nasociliary nerve of CN V1 (Sedaghat & Bleier, 2023). The anterior ethmoid nerve supplies the anterior-superior septum, and the posterior ethmoid nerve supplies the posterior-superior septum (Watters et al., 2022). In addition, the anterior septum is supplied by the anterior superior alveolar nerve of CN V2. The posteroinferior septum is supplied by the nasopalatine nerve, which is also a branch of CN V2 (Watters et al., 2022). Due to communication with the greater palatine nerve, injury of the nasopalatine nerve during removal of the maxillary crest may cause maxillary incisor numbness, which often only lasts for a short time (Sedaghat & Bleier, 2023).

Indications

(Watters et al., 2022; Sedaghat & Bleier, 2023)

  1. Symptomatic nasal obstruction refractory to medical therapy
  2. Recurrent epistaxis
  3. Obstructive sleep apnea
  4. Sinusitis
  5. Septal spurs that cause epistaxis and/or pain
  6. Improved access for endoscopic, orbital, and skull base surgery

Contraindications

(Watters et al., 2022)

  1. Concurrent diseases such as rhinosinusitis, vasculitis
  2. Active recreational drug use, in particular, intranasal cocaine use.

History solicited from patient

​​(Bhattacharyya, 2023; Chandra et al., 2009; Watters et al., 2022)

  1. Nasal symptoms
    1. Location (unilateral or bilateral), timing (seasonal variation), triggers (e.g., smoke, pets, chemicals),
  2. Symptoms of other pathologies
    1. Rhinosinusitis: facial pain/pressure, nasal congestion, purulent discharge, dysomia
    2. Malignancy: deformity, facial numbness
  3. Medications
    1. Nasal decongestants, oral contraceptives, antithyroid medication, antihypertensives, antidepressants, benzodiazepines
  4. Recreational drugs
    1. Intranasal cocaine
  5. Trauma, past nasal surgeries
  6. Medical history
    1. Asthma, syphilis, sarcoidosis, cystic fibrosis, granulomatosis with polyangiitis

Physical Exam of Patient

(Bhattacharyya, 2023; Chandra et al., 2009; Watters et al., 2022)

  1. External
    1. Signs of deformities, trauma, nasal tip deterioration or hypertrophy
    2. Assess nasal airflow after elevation of nasal tip to neutral position. If improved, potential disease of cartilage of nasal tip suggested. 
  2. Anterior rhinoscopy
    1. Performed with nasal speculum or otoscope.
    2. Assess for mucosal abnormalities, patency, collapse of soft tissues, septum position and size, inferior turbinate size, nasal cavity structure.
  3. Nasal endoscopy
    1. Can be performed if obstruction etiology is unclear, ongoing symptoms after initial treatment, and to evaluate posterior nasal space for disease or masses.

Surgical Approaches

1.     Endonasal septoplasty is also referred to as closed septoplasty. In this approach, all incisions are made inside the nostrils, and there are no external or visible scars.

2.     Endoscopic septoplasty involves the use of an endoscope, a thin tube with a camera, to visualize and access the nasal structures. This approach is less invasive and may be suitable for cases where better visualization is required.

3.     Open septoplasty involves making an incision on the external surface of the nose in addition to internal incisions. This approach is chosen when better visibility and access are necessary, particularly for complex cases.

Surgical Steps

(Note there are multiple approaches to surgical procedures – that below reflects and aggregate review from cited references)

1.  Inferior turbinate is out fractured laterally bilaterally

2.  Hairs are then trimmed with scissors

3.  Clear both nasal passages with epinephrine or pseudoephedrine-soaked pledge

4.  Inject 1 % lidocaine with 1:100,000 epinephrine into both sides of the nasal submucoperichondrial planes.

5.  May select the side with septal convexity for surgery to minimize mucosal tearing during flap elevation

6.  Two types of incisions can be made

a) hemitransfixion incision (most caudal aspect of septum)

b) killian incision (made more posteriorly)

7.  A 5mm incision is then made over the caudal septum with an ophthalmic crescent knife, 15 blade scalpel, or needle tip bovey

8.  The incision is taken down to but not through septal cartilage

9.   A mucoperichondral flap is then elevated off the cartilage using a cottle elevator and then

10.  In the subperichodrial/subperiosteal plane you will encounter the decussating dense fibers attachments to maxillary crest

11.  To carefully dissect and extend the flap from the nasal floor to the maxillary crest, employ a sweeping motion using a D-shaped knife or the belly of a 15-blade scalpel. Start the motion from the maxillary crest and proceed inferiorly towards the nasal floor.

12.  Endeavor to preserve the nasopalatine bundle that can been seen anteriorly during this step

13.  A pledget with epinephrine may be placed in the flap to assist with hemostasis

14.  The flap is then elevated anteriorly off the crest with a D-knife or other instrument

15.  Using a crescent knife or angled blade, make a cut (1-2mm) in the septal cartilage. Ensure the incision is made with effort to avoid fenestrating the mucoperichondrial flap on the contralateral side.

16.  The cartilage is then separated from the contralateral mucoperichondrial flap with a cottle elevator and raised posteriorly

17.  Once the flaps are elevated on both sides of the cartilage, appropriate amount of cartilage may be resected with biting instruments (jansen middleton) or swivel knife

18.  When septal cartilage, efforts are made to preserve an L-strut (1-1.5cm) to help avoid nasal saddling. Additionally, exercise caution if removing part of the ethmoid bone which is connected to the skull base and can extend a fracture superiorly

19.  When dealing with a deflection that includes the maxillary crest, position a caudal elevator between the bony crest and the septal cartilage, manipulating it in an upward direction (be careful not to entirely sever the crest, if feasible, as doing so could result in injury to the nasopalatine nerve and trigger problematic bleeding from the greater palatine artery)

20.  Septum is reassessed for straightening with the deviated aspect removed

21.  The L-strut concave surface of the cartilage may be scored with a crescent knife if needed to help break its memory

22.  The incision is closed using small chromic sutures, and quilting stitches that may be applied with a small Keith needle. This needle passes back through the septum to eliminate dead space, thereby diminishing the risk of hematoma formation.

A crescent knife may be utilized to create a small incision in the posterior septal mucosa, serving as an outlet for blood drainage (ideally not leading to septal perforation as it penetrates only one mucosal flap)

 

Complications

 

  1. Excessive Bleeding

- Substantial bleeding can be controlled with nasal packing, though in certain cases cautery may be necessary

      2.    Septal Hematoma (bleeding beneath mucoperichondrium)

- Evaluation for a hematoma is warranted to address at the end of the case

- Untreated hematoma may progress to infection, septal perforation, and/or saddle nose deformity

- If occurs, incisions of mucosa should be made under local anesthesia to evacuate clot

-  Packing bilaterally may be done to avoid re-accumulation

- If clear cause of hematoma is not apparent, coagulopathy may be considered

       3.    Septal Perforation

- Can occur subsequent to surgery when there are bilateral mucosal lacerations (ipsilateral perforations are occasionally inevitable and usually do not cause any complications)

- If opposing perforations are observed, an alloplastic or autologous interposition graft may be positioned between the flaps.

- Saddle nose may appear if the opening gets close to the keystone region

       4.    Infection

       5.    Nasal obstruction

 

Postoperative Care (Quinn et al., 2013; Dubin et al., 2009 ; Serin et al. 2010)

1.    Patients usually discharged on same day, but can be admitted if patient has history of using CPAP/BiPAP or use of nasal trumpets

2. Patients may receive nasal packing to prevent hematoma or bleeding and stabilize the cartilage to prevent further postoperative deviation. Nasal packing can increase postoperative pain and also lead to toxic shock

3.     Patients should sleep with head elevate

4.    Oral Analgesia are prescribed

5.    Nasal Saline Spray at least 4x a day

6.    Oral antibiotics may be prescribed

7.    No nose blowing for 1 week after surgery

8.    No Strenuous exercise for 2 weeks after surgery

 

References

​Alessandri-Bonetti M, Costantino A, Cottone G, et al. Efficacy of Septoplasty in Patients with Nasal Obstruction: A Systematic Review and Meta-analysis. Laryngoscope. 2023;133(12):3237-3246. doi:10.1002/lary.30684

Bhattacharyya N. Nasal obstruction: Diagnosis and management. UpToDate. November 22, 2023. Accessed November 27, 2023. https://www.uptodate.com/contents/nasal-obstruction-diagnosis-and-manage....

Carter, H.V. File: Gray814.png. Wikimedia Commons. 1918. Accessed December 3, 2023. https://commons.wikimedia.org/wiki/File:Gray514.png

Carter, H.V. File: Gray854.png. Wikimedia Commons. 1918. Accessed December 3, 2023. https://commons.wikimedia.org/wiki/File:Gray854.png.

Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway obstruction. Otolaryngol Clin North Am. 2009;42(2):207-vii. doi:10.1016/j.otc.2009.01.004

Dubin MR, Pletcher SD. Postoperative packing after septoplasty: is it necessary? Otolaryngol Clin North Am. 2009 Apr;42(2):279-85, viii-ix. doi: 10.1016/j.otc.2009.01.015. PMID: 19328892.

Haffey T, Pabon S, Hawley K, Hoschar A, Sindwani R. Exploring the clinical value and implications of routine pathological examination of septoplasty specimens. Laryngoscope. 2012;122(11):2373-2377. doi:10.1002/lary.23514

Quinn JG, Bonaparte JP, Kilty SJ. Postoperative management in the prevention of complications after septoplasty: a systematic review. Laryngoscope. 2013 Jun;123(6):1328-33. doi: 10.1002/lary.23848. Epub 2013 Apr 26. PMID: 23625653.

Sedaghat A, Bleier B. Septoplasty For Deviation of the Nasal . Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery. Accessed November 27, 2023. https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586f....

Serin GM, Polat S, Aksoy E, İnanlı S. Postoperative wound care regimen in open septorhinoplasty. J Craniofac Surg. 2010 Nov;21(6):1880-1. doi: 10.1097/SCS.0b013e3181f4aee2. PMID: 21119444.

Standring S, Gray H. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. Elsevier; 2021.

van Egmond MMHT, Rovers MM, Tillema AHJ, van Neerbeek N. Septoplasty for nasal obstruction due to a deviated nasal septum in adults: a systematic review. Rhinology. 2018;56(3):195-208. doi:10.4193/Rhin18.016

Watters C, Sabrina, Yapa S. Septoplasty. StatPearls - NCBI Bookshelf. November 8, 2022. Accessed November 27, 2023. https://www.ncbi.nlm.nih.gov/books/NBK567718/.