Septoplasty

Overview

Septoplasty is the surgical repair of nasal septum abnormalities and malformations (the partition between the nostrils). The septum is a bone and cartilage structure in the middle of the nose that divides one nasal cavity from another. A deviated septum can restrict one side of the nose and drastically disrupt airflow.

By removing the deviated section and rebuilding the remaining bone and cartilage, septoplasty seeks to straighten the septum as much as possible in the midline position and open the airway.

Septoplasty definition

Septoplasty is a frequent otolaryngology treatment performed to treat nasal blockage caused by a deviated nasal septum. The most common reason for this functional (rather than just cosmetic) surgery is septal deviation, which causes substantial and symptomatic nasal airway obstruction.

A deviated septum, which is a displacement of the wall between the nostrils, is frequently the origin of these obstructions. Turbinates, which are enlarged bone formations, may also obstruct sections of the nose.

Many surgical techniques and approaches, including endonasal, endoscopic, and open procedures, have been documented. To increase surgical exposure and access, septoplasty can be done with or in addition to rhinoplasty, turbinoplasty, or as part of functional endoscopic sinus surgery. Surgical recuperation normally takes a few weeks, and major complications are uncommon. Appropriate patient selection is critical to achieving the best possible patient outcomes.

Anatomy and Physiology

A thorough understanding of the anatomy of the nose, particularly the nasal septum, is essential for performing a successful septoplasty. The septum is the primary structural component of the external nose, supporting the nasal dorsum, columella, and nasal tip. It also divides the nasal cavity into two different nasal airways, allowing for warming, humification, and laminar airflow.

A septum deviation can lower the cross-sectional area of the nasal valve, resulting in airway obstruction. This can cause nasal obstruction and, in some cases, aggravate the symptoms of obstructive sleep apnea. Bony spurs caused by septal deviation can cause epistaxis, headaches (also known as "Sluder syndrome" or rhinogenic headache), and face discomfort.

Septal Structures

The septum is made up of three primary parts: membranous, cartilaginous, and bony. The membranous septum is formed of fibrous tissue and comprises the most anterior component of the cartilaginous septum between the caudal end and the medial crura of the lower lateral cartilages. The quadrangular cartilage, as the name implies, is quadrangular in form and is located posterior to this membranous part.

It connects to the maxillary crest in the back, the upper lateral cartilages in the front, and the bony septum in the back. The vomer, which is inferior-posterior to the cartilage, and the perpendicular plate of the ethmoid (PPE), which is superior-posterior, make up the bone septum. The ethmoid bone connects to the skull base and the sphenoid bone. The nasal bones are located on the upper nose's medial dorsal aspect, superior to the perpendicular plate.

Another important anatomical notion is the nasal valve, sometimes known as the "internal" nasal valve, which is the narrowest region of the nasal channel - a triangular area directly under the central portion of the nasal vault. The nasal valve is defined by the dorsal septum, the caudal boundary of the upper lateral cartilage, and the inferior turbinate head.

The classically described nasal valve angle is approximately 15 degrees, but it is often closer to 30 degrees; in approximately 50% of people, there will also be a septal swell body or "septal turbinate," which appears to be a wider portion of the dorsal septum at the level of the internal nasal valve. The swell body may appear to be a septal distortion when seen unilaterally, however it is usually symmetrical bilaterally.

The septum's connection with the anterior nasal spine of the maxilla and the "keystone region" are the two surgically crucial places of articulation. The keystone region is located at the junction of the nasal bones, quadrangular cartilage, upper lateral cartilages, and PPE; it is an important location for stability and structure and must be handled with care during septoplasty to prevent disturbing support for the nose dorsum. The keystone region is located just beneath the rhinion, a cephalometric point.

The septum's cartilaginous and bony components are covered with mucoperichondrium and mucoperiosteum, which give innervation and a plentiful vascular supply. This network of blood arteries allows for the warming and humidification of air as it passes through the nasal cavity. The surface mucosa is mostly composed of pseudostratified respiratory epithelial cells. The olfactory epithelium is placed more superiorly in the nasal cavity, near the olfactory cleft.

Blood Supply

The blood supply to the nasal septum is provided by a network of arteries that branch from the internal and external carotid arteries. The internal carotid artery gives birth to the anterior and posterior ethmoidal arteries, which supply the upper portion of the septum (through the ophthalmic artery). The external carotid artery gives birth to the facial and maxillary arteries, whose terminal branches feed the remaining circulatory supply; the facial artery branches form the superior labial artery, which serves the anterior portion of the nose.

The branches of the maxillary artery create the larger palatine and sphenopalatine arteries, which supply the inferior and posterior septums. They anastomose anteriorly to produce Keisselbach's plexus, also known as Little's region and the most common epistaxis location.

Innervation

The internal and external nose are innervated by the ophthalmic (V1) and maxillary (V2) branches of the trigeminal (V) cranial nerve. The anterior and posterior ethmoid nerves supply the anterior-superior and posterior-superior parts of the septum, respectively, from the nasociliary branch of the ophthalmic nerve (VI)

The nasopalatine branch of the maxillary nerve (V2) provides the septum's posteroinferior side. The anterior septum is supplied by the superior alveolar nerve, which is also a branch of the maxillary nerve. The olfactory nerve (I) transmits sensory information from the olfactory epithelium to the olfactory bulbs.

Indications

A nasal septal abnormality is the most common reason for a septoplasty. This is often caused by a deviation of the cartilaginous and/or bony sections of the septum into one or both nasal passageways, lowering the cross-sectional area, obstructing airflow, and generating a sense of nasal obstruction. Patients may have signs of blockage during exertion or when exercising in particular. Trauma is the most typical cause of the abnormality. Patients must be symptomatic with nasal obstruction in order for functional surgery to be performed.

To rate nasal obstructive symptoms, several grading methods are available. The Nasal Obstruction Symptom Evaluation (NOSE) scale is a well-validated tool for determining the degree of obstruction. Those who score low are unlikely to benefit from surgery. A detailed history is required to determine whether concurrent conditions, such as trauma, rhinosinusitis, allergies, vasculitis, illegal drug use, chronic use of decongestants, autoimmune illness, or cancer, may contribute to or cause blockage. In these circumstances, appropriate medical therapy (e.g., intranasal corticosteroids for persistent allergic rhinitis) should be administered as soon as possible.

Recurrent epistaxis, obstructive sleep apnea, sinusitis, and face discomfort and/or headaches caused by septal spurs that touch a turbinate are all reasons for septoplasty. Septoplasty may be required in combination with endoscopic sinus, skull, or orbital surgery to improve surgical access to pertinent tissues. 

Contraindications

There are various reasons why surgery should not be performed. Concurrent disorders such as rhinosinusitis or vasculitis, as well as situations in which proper medical care has not been performed, fall into this category. While nasal sprays will not correct a deviated septum, reducing chronic inflammation may alleviate symptomatic nasal blockage sufficiently to avoid surgical surgery. Furthermore, if conservative therapy has not been exhausted, third-party payers are reluctant to accept a costly surgical surgery.

The current recreational drug use, particularly intranasal cocaine, is extremely dangerous. Cocaine's vasoconstrictive and mucosal damaging effects might result in problems such as septal perforation, delayed healing, and, eventually, dorsal collapse with a saddle nose deformity.

Before operating, it is standard practice to verify that patients have been abstinent for at least 6 to 12 months, and toxicological test may be required. Similar measures should be used with individuals who exhibit symptoms of medicamentosa rhinitis. Vasoconstrictive decongestant nasal sprays should also be avoided for a substantial period before to surgery, however they can be effective in limiting intra- and post-operative hemorrhage.

Patients who have unreasonable expectations for the cosmetic or functional consequences of septoplasty should not be offered surgery unless significant pre-operative counseling is provided. This is especially true for individuals having concomitant rhinoplasty. The surgeon and patient must discuss realistic expectations in order to increase post-operative patient and surgeon satisfaction. Similarly, patients with septal deviation and deformity but little functional problems may gain little from surgery.

To assess if a general anesthesia would be safe and whether patients would be able to withstand the post-operative recovery phase, patient co-morbidities, functional status (ASA grade), and age must all be addressed.

Preparation

• History

A detailed history of the type and degree of the nasal symptoms should be collected. Other sinonasal or systemic pathologies, such as allergies, should be investigated. Nasal obstructive symptoms can be graded using scoring methods such as the NOSE scale. A thorough pharmacological history should be collected, with a special emphasis on intranasal decongestants and corticosteroids, as well as any recreational drug usage.

If the patient smokes, quitting should be explored, while smoking has not been proven to adversely affect results in nasoseptal surgery. It is important to note whether the patient has had past nose or sinus surgery, problems with prior anesthetics, or bleeding concerns.

• Examination

In the outpatient clinic, patients should be carefully examined. A complete head and neck exam should be performed, followed by an anterior rhinoscopy using a nasal speculum. Flexible nasendoscopy can be used to detect sinonasal illness or masses in the posterior nasal space. When examining the nasal septum, the surgeon should check for evidence of inflammation in the mucosa as well as the size and type of the turbinates, particularly the inferior turbinates.

A turbinoplasty may be necessary if access is restricted owing to too large turbinates. The septum should be palpated to assess the size, position, and type of the deviation, noting if it seems cartilaginous or bony and whether there are any septal perforations, dislocations, or bony spurs.

External inspection should be performed, noting any further deformity and degree of caudal tip support. Finally, Cottle's procedure should be used to evaluate internal valve stenosis. A comprehensive assessment will aid in establishing whether surgery is necessary, the amount of difficulty, and the best strategy and method for the patient.

Septoplasty surgery

Endonasal Preparation

• The patient is lying on his back with his head turned slightly towards the surgeon.
• Nasal hairs that protrude from the nose are clipped.
• Some surgeons prefer to use xylometazoline or Moffatt's solution to decongest the nose.
• Local anesthetic is infused bilaterally in the submucoperichondrial plane with 1% lidocaine mixed with adrenaline (1:100,000) until the mucosa is fully blanched. This aids in the hydro-dissection of the planes, as well as analgesia and hemostasis.

Closure

• The mucoperichondrial flaps are pushed back toward the septum. To seal the wound, interrupted stitches made of absorbable suture material (e.g., chromic gut) are utilized.
• Mattress, or "quilting," sutures are frequently used through-and-through the septum to cover any dead space and reaproximate the flaps to reduce post-operative hematoma collection. If the mucoperichondrial flaps are totally intact at the conclusion of the procedure, some surgeons will make a tiny incision inferiorly in one flap to allow any fluid that may have collected within the septum to escape.
• Sometimes splints made of silicone are necessary. These are trimmed to size, sutured transseptally, and positioned close to the septum for simple removal in the outpatient clinic. If the turbinates are hypertrophied or turbinoplasties have been done, the splints are designed to avoid adhesions.
• Intranasal antibiotic cream can be used.

Endoscopic

The numerous processes and strategies employed are comparable to the standard endonasal approach. To see the nasal structures and septum, a 0 degree Hopkins rod endoscope is utilized instead of a nasal speculum and illumination. To guarantee effective resection, the endoscope can be positioned between mucosal flaps.

This procedure is more typically employed in combination with functional endoscopic sinus surgery (FESS), which already requires endoscopic methods. Endoscopic access to an isolated septal deformity is frequently obtained using a Killian incision, which may be done slightly anterior to a bony spur to simplify access and minimize elevation of entire mucoperichondrial flaps all the way back from a hemi-transfixion incision.

Endoscopic procedures improve visibility and provide a magnified picture of the anatomy. This is very useful for instructing more rookie surgeons. Endonasal surgeries are notoriously difficult to watch, making training difficult. Endoscopic visualization can also assist in identifying the right dissection planes in revision situations where scarring or adhesions are present.

Endoscopic septoplasties, on the other hand, may be more technically difficult than endonasal techniques. Even senior surgeons skilled in endonasal and FESS surgery may need to do 60 operations before reaching acceptable operational timeframes and a low complication rate. Endoscopically correcting anterior flaws can be especially difficult since the surgeon cannot readily stabilize the endoscope and may have to adopt a "free-hand" method.

Extracorporeal

Complex septal abnormalities in all three locations (quadrangular cartilage, PPE, and vomer) or previous comminuted fractures may make the aforementioned procedures difficult or impossible to implement. Extracorporeal techniques, in which the entire septal cartilage is removed, the distortion is rectified, and the septum is subsequently reinstalled, may be required in this scenario. This can be done as an open operation using a rhinoplasty approach, as part of a septorhinoplasty, or as a closed treatment with an extended hemi-transfixion incision.

After the septum has been removed, many treatments for straightening it have been documented. Making partial-thickness incisions on the concave side of the deviation, incising fracture lines and re-suturing component portions together, affixing grafts to overlap and splint the deviated cartilage, or drilling/filing sections of the septum are examples of these procedures.

Suturing removed septal cartilage fragments to a polydioxanone scaffolding plate is an alternate approach that is especially beneficial when just a little amount of cartilage remains within the septum. If a new orientation gives better structural support, the cartilage can be rotated and replaced. The lateral cartilages and anterior nasal spine must then be reimplanted and sutured.

In circumstances when there is little cartilaginous septum left (due to previous surgery or necrosis), a neoseptum can be created using pieces of existing septal cartilage or autologous material, such as costal cartilage. Homologous grafts (homologous costal cartilage taken from cadaveric donors) are another option.

Post-operative Care

• Patients are frequently allowed to leave the hospital the same day.
• Naseptin cream and analgesic tablets are administered.
• During the healing phase, oxymetazoline and saline sprays may also be beneficial in establishing a clean intranasal environment.
• The patient will need to be visited in 1 to 2 weeks for a post-operative evaluation and removal of any splints that were utilized.
• Antibiotics are rarely necessary. Antibiotics to prevent staphylococcal toxic shock may be required if gauze packing is used to support comminuted bone fragments.

Complications

A variety of issues may arise as a result of septoplasty procedures; they must be properly detailed and explained to the patient during the informed consent conversation. Excessive bleeding is the most common; some seeping is to be expected, but more severe bleeding is controllable with nasal packing and may necessitate cautery in rare cases.

Septal hematomas form when bleeding occurs underneath the mucoperichondrium and require drainage or aspiration to prevent the formation of a septal hole. Perforations can also occur intraoperatively as a result of bilateral, opposing mucosal perforations; if a perforation approaches the keystone region, a saddle nose deformity may emerge, necessitating revision surgery.

Infection, nasal blockage, and delayed healing can all occur in certain people. Infections are uncommon and can usually be treated with oral antibiotics; the great majority of patients will recover completely within a few weeks.

Hyposmia has been seen in certain people (particularly often in patients undergoing concomitant turbinoplasty surgeries); this normally disappears within six months. Intranasal adhesions can occur, although using silastic splints reduces the likelihood of this problem. Finally, patients may develop numbness or sensitivity of the upper teeth or lip as a result of intraoperative nasopalatine nerve manipulation; this condition is generally temporary, and normal feeling recovers within a few months.

Septoplasty cost

Your costs with insurance will depend on your plan but might include:

• a copayment or coinsurance
• any part of your deductible you have remaining
• any costs for noncovered services

Most insurance policies will not fund septoplasty only for aesthetic reasons. Your expenses will be determined by where you have your treatment performed and what the surgery entails. When looking for a surgeon in your region, you may come across prices as low as $6,000 or as high as $30,000.

Conclusion 

Septoplasty is one of the most common ENT operations done. Long-term patient outcomes for most patients with septal deviation-related obstructive symptoms have been shown to be satisfactory in systematic evaluations. Despite this, a considerable number of patients have post-surgery return of obstructive symptoms, and satisfaction rates can be very varied .

Patient satisfaction, quality of life, and symptom improvement questionnaires are routinely used to measure postoperative results. It is difficult to assess symptom improvement since it is typically subjective and changeable during the day, and objective tests, such as acoustic rhinometry and rhinomanometry, do not necessarily correspond with patient impression.

Candidates for surgery are evaluated clinically, and it is unclear in the literature whether prognostic markers influence satisfactory postoperative results. In the future, a mix of objective and subjective metrics to select potential patients may assist enhance results.