General Medical Information

Deviated Nasal Septum

Richard L. Mabry

Deviated septum is the most common cause of nasal obstruction. Among patients with nasal septal deviation, a history of nasal or midfacial trauma often indicates the original alteration of normal nasal anatomic features. Improper forceps placement or birth through an unusually narrow pelvic canal can cause septal deviation early in anatomic development. Trauma can displace anatomic features externally, such as nasal bones or upper lateral cartilage, internally, or as a combination of external and internal alterations. Internal deviation can be caused by singular or concerted alteration of the bony portion or cartilaginous portion of the septum; however, bony alteration of the posterior septum (the vomer or perpendicular plate of the ethmoid) is less frequent. Patients with unilateral septal deviation most often have nasal obstruction of the contralateral side.

Nasal turbinate bone hypertrophy can be caused by a lack of structural resistance by the nasal septum. Turbinate mucosal hypertrophy occurs as a reaction to external stimuli, such as allergens, or in the nasal cycle when atrophy alternates between the right and left nasal passages in a cyclic manner. When the nasal septum is deviated, mucosal swelling on the contralateral side does not have proper resistance to growth. This mucosa can swell unabated, whereas the ipsilateral side is hypotrophic. Normal hypertrophic mucosa encounters the nasal septum and shrinks to reestablish nasal patency. Many patients with nasal septal deviation have a history of recurrent sinusitis. Because of the existence of hypertrophic mucosa, a patient with a deviated septum also can have a history of chronic sinusitis. Chronic sinusitis as a secondary condition can be caused by unilateral or bilateral impingement of the nasal passage. Impingement reduces nasal airflow through turbulent resistance and can induce thickening, atrophic mucosal changes, or crusting of the nasal mucosa. These changes can block the sinus ostia and proper sinus drainage on the contralateral or ipsilateral side. For this reason, septoplasty often is combined with concurrent functional endoscopic surgical procedures on the sinus, submucous resection of the inferior or middle turbinates, or rhinoplasty.

Medical treatment centers on the use of aerosol or aqueous steroid nasal spray. Antihistamines can be used if coincident allergic rhinitis is suspected. Use of decongestant sprays should be avoided because anatomic nasal obstruction is a chronic problem, and use of these medicines risks development of rhinitis medicamentosa. Medical management may not provide relief to patients with hypertrophic turbinates due to septal deviation. These patients need surgical treatment.
Septoplasty alleviates nasal obstruction by means of surgical resection of impinging anterior cartilaginous or posterior osseous septal deviation. Nasal septal surgery involves conservative resection of the septum. The surgeon resects only the deviated portion of the septum, allowing maximal preservation of this important structural component of the nose. The nasal septum provides structural support to the nasal dorsum and a medial boundary to turbinate enlargement. Critical to successful outcome in septal surgery is thorough preoperative evaluation that identifies the areas where the symptoms arise.

Septoplasty is performed with local or general anesthetic. The latter is preferred for operations on patients who are apprehensive about surgery or when transnasal surgery is anticipated. Subperichondrial injection of hemostatic solution such as lidocaine 1% with 1:200,000 epinephrine is critical to hemostasis. Placement of the incision depends on the specific area of the septum that needs to be addressed. If the caudal quadrangular cartilage is dislocated from the anterior nasal spine, a hemitransfixion incision is preferred for access to this area. This incision passes through the membranous septum between the medial crura of the lower lateral cartilages and the caudal quadrangular cartilage.

When obstruction involves the posterior cartilaginous septum or the bony septum, a Killian incision (vertical incision about 1 to 2 cm from the columella) is preferred. After the incision is made, a mucoperichondrial-mucoperiosteal flap is raised in the subperichondrial-subperiosteal plane on the side of the incision. Before any cartilage or bone is removed, the mucoperichondrium-mucoperiosteum on the contralateral side is also raised. Access to the contralateral side is either through the septum or around the caudal septum, depending on the exposure. Deviated portions of the septum are identified and removed. The classic submucosal resection involves removal of the septum except for a 1-cm wide dorsal and caudal strut that remains for nasal support. Conservation resection usually is adequate. Septal spurs due to overgrowth of the maxillary crest can be removed with an osteotome. Resection of the bony septum is accomplished with Jansen-Middleton rongeurs. Care is taken not to rock the perpendicular plate of the ethmoid bone. Rocking can cause cerebrospinal rhinorrhea through a fracture of the cribriform plate. Care also is taken to avoid tearing the septal flaps, because bilateral tears can cause septal perforation.

When deviation involves the dorsal strut of the septum, removal of the deviated portion followed by reconstruction with straight cartilage grafts may be needed to straighten the septum and avoid loss of nasal tip support. As much cartilage as can be conserved should be conserved. The surgeon needs to be wary of leaving deformed cartilage in place, which can cause renewed obstruction. Deformed cartilage can be crushed or scored to reduce the likelihood of memory in the cartilage, which can cause poor results. These methods often fail to prevent the cartilage from returning to its curved, undesirable configuration. After the cartilaginous structure is fixed, the septal flaps are approximated with a horizontal mattress (plicating) absorbable suture. Nasal splints or nasal packing sometimes are used. Submucous turbinate resection and other related procedures can be performed to increase the effectiveness of septoplasty in restoring nasal patency.

Combined with septoplasty, rhinoplasty serves as an external complement. In the management of obstruction, rhinoplasty is used primarily as a functional rather than a cosmetic procedure. It is performed through the intranasal or external route. Exposure is gained and conservative resection of redundant cartilage or bone is performed along the nasal dorsum.