Septoplasty

Author Credentials 

Philip G. Chen, MD
Assistant Professor
Christian L. Stallworth, MD
Clinical Assistant Professor
Department of Otolaryngology – Head and Neck Surgery
University of Texas Health San Antonio
7703 Floyd Curl Dr., MC 7777
San Antonio, TX 78229

Module Summary

Nasal obstruction is a common nasal complaint that may result from singular unilateral or bilateral anatomic perturbations. However, patients are commonly identified as having two or more factors working in concert to collectively impede nasal function. These may include combinations of septal deviation, fixed and dynamic obstruction of the internal and external nasal valves, and the effects of hypertrophied inferior turbinates. Using this module as a reference for review, the nasal surgeon should find reinforcement for a thorough understanding of nasal anatomy, familiarity with comprehensive nasal examination, and recognition of the etiologies responsible for obstruction. Once identified, the surgeon will then be better equipped to devise an operative plan tailored to address each of the factors contributing to their patient’s nasal obstruction.

Module Learning Objectives 
  1. Describe the physiology of nasal airflow and understand the varying etiologies that contribute to nasal obstruction.
  2. Describe in detail the physical exam for nasal obstruction.
  3. Identify the fixed and dynamic properties of the internal and external nasal valves, and describe how these combine to influence nasal resistance.
  4. Describe the varied approaches used to address septal deviation and indications for each.
  5. Explain the data for multiple surgical approaches to address inferior turbinate hypertrophy.

Anatomy

Learning Objectives 
  1. List the bone and cartilage constituents of the nasal septum.
  2. List the common causes of septal deviation
    1. Congenital / genetic
    2. Birth / childhood trauma
    3. Craniofacial growth
    4. Adult trauma
    5. Endonasal drug use
    6. Autoimmune and sinonasal disorders
  3. List the borders of the internal and external nasal valves.
  4. Understand the multiple locations causing nasal obstruction.

 

References 
  1. Haight JS, Cole P. The site and function of the nasal valve. Larnyoscope. 1983 Jan;93(1):49-55.
  2. Tardy ME, Brown R. Surgical Anatomy of the Nose. New York: Raven Press; 1990.

Pathogenesis

Learning Objectives 
  1. Describe medical (non-anatomic) causes for nasal obstruction.
  2. Describe the fixed and dynamic anatomic causes for nasal obstruction.
  3. Explain the role of trauma in nasal obstruction.

 

Basic Science

Learning Objectives 
  1. Air-fluid dynamics
  2. Nasal resistance and role in pulmonary function
References 
  1. Kasperbauer JL, Kern EB. Nasal valve physiology: implications in nasal surgery. Otolaryngol Clin North Am. 1987;20:699–719
  2. Bailey B, ed. Nasal function and evaluation, nasal obstruction. Head and Neck Surgery: Otolaryngology. 2nd ed. New York, NY: Lippincott-Raven; 1998:335-44, 376, 380-90.

Genetics

Learning Objectives 

Recognize the common differences in nasal architecture between varying ethnic groups and appreciate how these differences impact nasal function.

 

References 
  1. Romo T & Abraham MT. The Ethnic Nose. Facial Plastic Surgery. 2003;19(3):269-277.
  2. Wang TD. Non-Caucasian Rhinoplasty. Facial Plastic Surgery. 2003;19(3):247-255.

Patient Evaluation

Learning Objectives 
  1. History of nasal obstruction
    1. Onset
    2. Modifying factors that improve or exacerbate nasal obstruction
    3. Laterality
  2. Physical Exam
    1. Visual inspection and palpation of the nose at rest and with inspiration
    2. Anterior rhinoscopy
    3. Endoscopic Exam
    4. Cottle and Modified Cottle maneuvers
    5. Role of topical decongestants
References 
  1. Murrell GL. Components of the nasal examination. Aesthet Surg J. 2013;33(1):38-42.

Measurement of Functional Status

Learning Objectives 
  1. Identify the role of the validated NOSE Questionaire in patients with nasal obstruction.
  2. Explain the pros and cons us using acoustic rhinometry in patients with nasal obstruction.
References 
  1. Rhee JS, Sullivan CD, Frank DO, Kimbell JS, Garcia GJ. A systematic review of patient reported nasal obstruction scores: Defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg. 2014 May-Jun;16(3):219-25; quiz 232.
  2. Roithmann R, Cole P, Chapnik J, et al. Acoustic rhinometry, rhinomanometry, and the sensation of nasal patency: a correlative study. J Otolaryngol. 1994;23:454-458.
  3. Stewart MG, Smith TL, Weaver EM, et al. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130(2):157–63.
  4. Most SP. Analysis of Outcomes After Functional Rhinoplasy Using a Disease-Specific Quality of Life Instrument. Arch Facial Plast Surg. 2006;8(5):306-309.

Imaging

Learning Objectives 

Understand the importance of history and physical examination, and discuss the role of radiologic imaging.

References 
  1. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010;143:48-59.

Pathology

Learning Objectives 

Explain the pathophysiology of rhinitis medicamentosa.

References 
  1. Doshi J. Rhinitis medicamentosa: what an otolaryngologist needs to know. Eur Arch Otorhinolaryngol. 2009;266(5):623-5.
  2. Settipane RA, Kaliner MA. Chapter 14: Nonallergic rhinitis. Am J Rhinol Allergy. 2013;27 Suppl 1:S48-51.

Treatment

Learning Objectives 

Be able to prescribe a treatment algorithm for a patient suffering with rhinitis medicamentosa.

References 
  1. Doshi J. Rhinitis medicamentosa: what an otolaryngologist needs to know. Eur Arch Otorhinolaryngol. 2009 May;266(5):623-5.

Medical Therapies

Learning Objectives 

Understand the role of non-surgcial therapies in nasal obstruction, and what evidence exists for their use (or non-use):

  1. Intranasal corticosteroids
  2. Saline irrigation / moisturizers
  3. External nasal strips
  4. Endonasal cones/dilators
References 
  1. Baker DC. Treatment of obstructive inferior turbinates with intranasal corticosteroids. Ann Plast Surg. 1979 Sep;3:253-9.
  2. Griffin JW, Hunter G, Ferguson D, Sillers MJ. Physiologic effects of an external nasal dilator. Laryngoscope. 1997;107:1235-1238.

Surgical Therapies

Learning Objectives 
  1. Correction of septal deviation
    1. Describe the factors that help one determine whether to perform an endonasal vs. endoscopic septoplasty
    2. Endonasal (headlight) septoplasty
      1. Killian vs. Hemitransfixion vs. Transfixion Incisions
    3. Open rhinoplasty approach to the septum
    4. Extracorporeal septoplasty
  2. Repair of the nasal valve
    1. List rhinioplasty maneuvers that address the Internal Nasal Valve, and describe situations to use each of them
      1. Spreader graft
      2. Autospreader grafts
      3. Flaring sutures
      4. Butterfly graft
    2. List rhinioplasty maneuvers that address the External Nasal Valve, and describe situations to use each of them
      1. Batten grafts
      2. Alar strut grafts
      3. Alar rim grafts
      4. Butterfly graft
      5. Artificial implants
        1. Latera Spirox
        2. ALAR nasal valve stent
  3. Recognize the multiple methods of surgically addressing hypertrophic inferior turbinates
  4. Discuss the pros and cons of each method and the expected longevity of each procedure
    1. Radiofrequency ablation
    2. Electrocautery
    3. Submucosal tissue ablation
    4. Formal reduction with removal conchal bone
  5. Discuss the pros and cons of performing septorhinoplasty concurrently with endoscopic sinus surgery
References 
  1. Hong CJ, Monteiro E, Badhiwala J, et al. Open versus endoscopic septoplasty techniques: A systematic review and meta-analysis. Am J Rhinol Allergy. 2016 Nov 1;30(6):436-442.
  2. Haack J & Papel ID. Caudal Septal Deviation. Otolaryngol Clin N Am. 2009;42:427-436.
  3. Most SP. Anterior Septal Reconstruction. Outcomes After a Modified Extracorporeal Septoplasty Technique. Arch Facial Plast Surg. 2006;8:202-207.
  4. Clark JM, Cook TA. The butterfly graft in functional secondary rhinoplasty. Laryngoscope. 2002;112:1917-1925.
  5. Friedman O & Cook TA. Conchal Cartilage Butterfly Graft in Primary Functional Rhinoplasty. Laryngoscope. 2009; 119:255-262.
  6. Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg. 1998;101:1120–1122.
  7. Sheen JH. Spreader graft: a method of reconstruction the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230-239.
  8. Clark JM, Cook TA. The butterfly graft in functional secondary rhinoplasty. Laryngoscope. 2002;112:1917-1925.
  9. Friedman O & Cook TA. Conchal Cartilage Butterfly Graft in Primary Functional Rhinoplasty. Laryngoscope. 2009;119:255-262.
  10. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010;143:48-59.
  11. Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of Alar Batten Grafts for Correction of Nasal Valve Collapse. Arch Otolaryngol Head Neck Surg. 1997;123:802-808.
  12. Most SP. Analysis of Outcomes After Functional Rhinoplasty Using a Disease-Specific Quality of Life Instrument. Arch Facial Plast Surg. 2006;8(5):306-309.
  13. Barham HP, Thornton MA, Knisely A, Marcells GN, Harvey RJ, Sacks R. Long-term outcomes in medial flap inferior turbinoplasty are superior to submucosal electrocautery and submucosal powered turbinate reduction. Int Forum Allergy Rhinol. 2016 Feb;6(2):143-7.
  14. Acevedo JL, Camacho M, Brietzke SE. Radiofrequency Ablation Turbinoplasty versus Microdebrider-Assisted Turbinoplasty: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2015 Dec;153(6):951-6.
  15. Patel ZM, Setzen M, Sclafani AP, Del Gaudio JM. Concurrent functional endoscopic sinus surgery and septorhinoplasty: using evidence to make clinical decisions. Int Forum Allergy Rhinol. 2013 Jun;3(6):488-92.
  16. Marcus B, Patel Z, Busquets J, Hwang PH, Cook TA. The utility of concurrent rhinoplasty and sinus surgery: a 2-team approach. Arch Facial Plast Surg. 2006 Jul-Aug;8(4):260-2.
  17. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Case Studies

  1. A 50 year-old woman presents complaining of reported recurrent sinusitis worsening over 5 years. Her symptom is primarily bilateral nasal obstruction which is persistent and worse with laying supine. She is an avid jogger and seems to have worsening obstruction during these times. She has been compliant and treated with multiple courses of antibiotics, oral steroids, nasal saline irrigations, and nasal steroids. A recent CT scan of the sinus is completely free of mucosal thickening. What does your physical exam consist of, and what might you find? What other information might help you make a diagnosis? Does she need additional radiographic imaging? What options does she have for treatment?
  2. A 30 year-old male presents with unilateral left nasal ala collapse that he demonstrates on inspiration. This is particularly bothersome during exercise. He demonstrates the ability to pull his cheek laterally to assist with his airway. He often sleeps holding this left cheek as well. On exam, you visibly and palbably recognize a weak left nasal ala, together with a left caudal septal deflection further narrowing the vestibule. There is mid and posterior septal deflection of the quadrangular cartilage back to the right, leaving a broad septal concavity on the left. There is left sided compensatory inferior turbinate hypertrophy. Explain the physical exam of this patient and itemize the multiple levels of airway obstruction. What are the options for repair of each level of obstruction? Are their non-surgical options available for this patient? What are the surgical options and how may these be perfomed separately or combined?
  3. A 72-year old male presents with a history of sleep apnea. He currently uses CPAP, but has had progressive nasal airway obstruction over the last decade. He had a septoplasty in his 30’s and breathed well for most of his adult life. On exam, his septum is midline and intact. Turbinates are atrophic and non-obstructive. You identify tip ptosis, a palpably weak lower third of the nose, and he respondes to both Cottle and modified Cottle maneuvers with marked improved of his perceived obstruction. What is the cause for his relatively new airway obstruction? What interventions are available to help correct his obstruction? Based on his medical history, the patient elects to forego formal surgery under anesthesia. Are their other less invasive options available to correct his nasal obstruction?

Complications

Learning Objectives 
  1. List causes for post-operative septal deformity, and understand the reasons for resulting deformity.
  2. Explain the pros and cons of nasal packing and splints after septal surgery.
  3. Discuss the theory behind atrophic rhinitis or empty nose syndrome.
References 
  1. Dubin MR, Pletcher SD. Postoperative packing after septoplasty: is it necessary? Otolaryngol Clin North Am. 2009 Apr;42(2):279-85, viii-ix.
  2. Kim DW, Gurney T. Management of naso-septal L-strut deformities. Facial Plast Surg. 2006 Feb;22(1):9-27.
  3. Kim JS, Kwon SH. Is nonabsorbable nasal packing after septoplasty essential? A meta-analysis. Laryngoscope. 2016 Nov 30.
  4. Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol. 2001;15(6):355–61.

Review

Review Questions 
  1. What are some of the major complications of septoplasty and how can they be avoided?
  2. Explain what the internal nasal valve is and the detailed physical exam of the nasal valve.
  3. What are some non-surgical options to treat nasal valve obstruction? How might these benefit both the treatment and diagnosis of patients with subjective nasal airway obstruction?
  4. A patient presents with multi-level airway obstruction involving the septum, turbinates, and nasal valves. Devise an operative plan that might address all aspects of her obstruction in a single operation.
Resources 

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