Septoplasty - surgery of the nasal septum
Septoplasty is an operation by which we improve nasal breathing and other related functions of the nose. It is often associated with rhinoplasty, although the meaning of the procedure is completely separate from the aesthetic procedure.
The nose plays a key role in active breathing and the exchange of oxygen and CO2 in the lungs. Consequently, nasal breathing disorders can have far-reaching somatic and psychological effects on the patient.
A patient with disturbed nasal breathing and poor physiology requires taking a complete medical history, a careful clinical examination, laboratory tests and a thorough interview before surgical intervention.
DIAGNOSIS OF DIFFICULT BREATHING
The main diagnostic goal in difficult nasal breathing is to determine whether the patient’s disturbed physiology is primarily related to
- mucosal disorder
- structural abnormalities of the septum or
- both of you.
If the patient’s statement suggests so called mucous (mucous) component as a cause of complaints such as caused by chronic inflammation seen in allergic rhinitis or chronic rhinosinusitis, then appropriate medical therapy should be initiated and improvement assessed after appropriate therapeutic trial before resolution of structural abnormalities. Local nasal steroids and local and oral antihistamines have been shown to be effective in the treatment of rhinitis.
The key elements that are required in the medical history are:
- allergy symptoms and non-allergic rhinitis
- chronic and acute sinusitis
- local nasal abuse of decongestants (nose drops)
- use of medications for hypertension and a history of hypothyroidism or
These are just some of the causes of mucosal abnormalities that can produce disturbed nasal physiology and symptoms.
In solving so called structural abnormalities which may be related to disturbed air flow, it is important to assess
- condition of the septum (nasal septum) and upper lateral (triangular) cartilages
- the structure and position of the lower lateral cartilages (alar), the area of the nasal wings and the lateral nasal wall (especially the lower nasal concha).
- The size of the inferior turbinate should also be assessed as it may contribute to nasal congestion.
In the diagnosis of disturbed nasal breathing, the first and most important method is a classical rhinological examination with an additional endoscopy of the nose.
In addition, we can use reliable nasal function tests that ideally quantify abnormal nasal physiology and provide treatment guidelines. Today, in practice, most such tests are impractical to perform.
Examination of the patient’s nose should be correlated with the patient’s complaints. Rhinological examination should include assessment of all described external deformities. Region so called nasal valves, must be carefully evaluated, since this is the most common site of symptoms of septal deformity. This may require the use of a nasal speculum or retractor to allow visualization of the vestibule and nasal valve area with minimal distortion. The position of the septum should be evaluated in relation to the lower lateral cartilage, nasal dorsum, premaxilla and the rest of the nasal valve area. Both the internal and external nasal valves should be assessed. The external nasal valve is the first area of resistance and consists of the area of the nasal vestibule below the nasal oral cavity formed by the caudal septum, the alar edge and the medial crura of the alar cartilage. The internal nasal valve consists of the dorsal septum, the caudal border of the upper lateral cartilage, and the anterior aspect of the lower nasal concha.
After thorough visualization of the nasal cavity, it is often useful to use a rigid or flexible endoscope to further evaluate the middle and posterior part of the nasal cavity. This can easily be done after topical application of 1% phenylephrine hydrochloride.
Deformities of the middle septum can often be observed, which are generally asymptomatic from an obstructive point of view. However, they may appear with vague facial pain or recurrent sinusitis.
Rhinomanometry provides objective data on the respiratory function of the nasal airway. Rhinomanometry quantifies nasal airflow and pressure, allowing calculation of airway resistance. There are three methods for measuring airflow:
- Anterior rhinomanometry relies on a catheter placed in the nasal vestibule to measure pressure changes on the opposite side of the nose.
- Posterior rhinomanometry involves the peroral placement of a catheter in the oropharynx, which allows both sides of the nose to be measured simultaneously.
There are also olfactory tests, such as the readily available tool (University of Pennsylvania Smell Identification Test – UPSIT) and commercially available odors that are used in an individualized manner.
The usefulness of olfactory testing is easily recognized when a patient who has had nose surgery presents with complaints of reduced olfactory function. Mechanisms responsible for olfactory injury caused by nasal surgery include direct trauma to the olfactory epithelium, vascular damage to the neuroepithelium during surgery, adverse drug effects, atrophic rhinitis
due to excessive removal of intranasal tissue, mucosal edema due to (or aggravated by) surgical trauma that prevents air access to the neuroepithelium, and idiopathic development of anosmia in the postoperative period.
Olfactory testing is not routinely performed for patients undergoing nasal and paranasal sinus surgery due to the need for additional time and expense. However, the utility of routine olfactory testing becomes clear when the surgeon is faced with a patient who reports a change in sense of smell after nose surgery.
The final aspect of the preoperative assessment consists of a patient interview, physical examination, and laboratory studies, including the etiology of the deranged nasal physiology.
A planned therapeutic approach includes a discussion of alternative therapies, an assessment of the likelihood of success, and, if surgery is required, the postoperative recovery time and the chance of possible reoperation.
The approach to nasal septum reconstructive surgery is based on several principles and concepts:
- First, the goal of surgery is to remove the pathology and reconstruct the abnormal parts of the septum into a normal position so that normal physiological airway function can take place.
- Second, the goal of minimally invasive surgery (incisions and subsequent dissections) is to completely reveal the pathological structures of the septum.
- Third, the mucous membrane is a valuable organ of the nose where defense and biochemical reactions take place, and incisions should be very gentle in order to preserve the integrity of the mucosa.
- Fourth, the goal of surgery is to help the patient eliminate symptoms.
Reconstructive surgery of the nasal septum is indeed reconstruction, with the final steps involving the replacement and fixation of the appropriately trimmed cartilage and bone within the septal mucosa. Basically, bone is replaced where bone used to be, and cartilage is replaced where cartilage used to be.
Nasal septum surgery can be performed either under general anesthesia or under local anesthesia with intravenous sedation.
End of operation
Completion of the operation involves closing the hemitransfixion incision with resorbable sutures. The nasal cavities should be temporarily closed to keep the reconstructed septum in the midline and prevent hematoma formation. There are two options available to achieve this.
- Plastic nasal stents sutured to the septum with subsequently applied antibiotic-impregnated gauze nasal tamponade.
- An alternative method is suturing mucoperichondrial flaps with resorbable suture, which avoids the need for nasal tamponade. However, if significant reconstructive efforts have been undertaken or if bone has been transplanted anteriorly into the septal space due to cartilage deformation, such a method is not recommended.
Endoscopic visualization provides several advantages to septoplasty. It allows the surgeon to visualize subtle isolated septal bulges and posteriorly located deviations that may not be recognized by a classic examination. It also provides improved illumination to reduce trauma to the septal mucosa in experienced hands. In addition, endoscopic septoplasty allows multiple persons to see the operation and therefore provides an excellent teaching tool for surgeons to understand the anatomy and technique of septoplasty.
Indications for endoscopic septoplasty are similar to traditional septoplasty, mainly removal of anatomical obstruction to improve functional nasal breathing. In addition, endoscopic septoplasty can be performed together with endoscopic sinus surgery. In cases where the patient has moderate or severe septal deviation, it is necessary to pay attention to this deviation in order to allow endoscopic access to the maxillary and ethmoid sinuses. Complications of endoscopic sinus surgery do not differ from traditional septoplasty with the help of frontal lighting.
Endoscopic septoplasty is performed in a similar way to traditional septoplasty. Instrumentation for endoscopic septoplasty does not differ significantly from traditional headlamp septoplasty.
Before performing endoscopic or traditional septoplasty, sinonasal computed tomography (CT) can help identify structural anomalies that may contribute to functional nasal obstruction and should be addressed at the time of surgery.
Previous unsuccessful operations
Patients with nasal airway obstruction and a history of previous rhinologic surgery are challenging for several reasons. First, previous surgery creates scar tissue, which makes surgical dissection difficult. Second, there is a high probability that a significant portion of the cartilage and bony skeleton may be absent, increasing the difficulty of dissection and the likelihood of complications that may require the use of autograft from a distant site or allograft for septal reconstruction.
These factors not only lead to more difficult mucoperiosteal dissection, but also increase the risk of mucosal flap rupture. Therefore, it is done in a technically more difficult environment with fewer resources available for reconstruction. In addition, both physiological and psychological difficulties are more complex, so a thoughtful and thorough preoperative interview is mandatory.
It is interesting to mention that it is often the case that patients who have already had one (or more) aesthetic correction of the nose appear, and that the problem of the septum has been neglected.
Reconstructive septum surgeries are often performed as one-day surgeries. The patient is discharged with a small amount of painkillers and antibiotics. Patients are advised to avoid heavy lifting for 10 days. Additional air humidification is recommended to prevent symptomatic drying of the upper airways. If the nose is packed with tamponade, detamponade is usually done after 3-5 days. Plastic stents (if placed) are usually removed 7 to 10 days after surgery, depending on the need to protect the mucosa and prevent adhesions.
Complications can be divided into three possibilities.
Possible intraoperative complications include adverse reactions to the local anesthetic, alone or in combination with general anesthesia. Excessive intraoperative bleeding is uncommon and is treated with electrocautery. Temporary tamponade with adrenaline can also be helpful.
Bleeding after nasal septum reconstruction surgery is rare, but requires immediate treatment. If bleeding is minimal, local measures such as gentle pressure may be sufficient. If bleeding has followed removal of the tamponade, the application of a local vasoconstrictor may be useful. If other measures fail, the nose may need to be packed again.
Usually, nasal septum reconstruction surgery causes minimal discomfort. Severe nasal pain warrants immediate reevaluation for the possibility of a septal hematoma or abscess. The presence of fever or toxic symptoms requires removal of the dressing and consideration of drainage and intravenous antibiotic therapy, with activity for Staphylococcus aureus because of reported cases of toxic shock syndrome. Although not proven to be effective as a preventative against toxic shock syndrome, nasal tamponade is impregnated with antibiotic ointment to prevent bacterial overgrowth.
- The most common late postoperative complication is the recurrence of septal deformity, although this is uncommon. It can occur due to postoperative scar tissue contracture or nasal trauma. If the patient’s nasal breathing is disturbed due to recurrent deformity, reoperation is considered. It is usually suggested that 12 months pass before reoperation. This allows scar tissue to contract and mature.
- Septal perforations are not common after septal surgery, and surgical trauma is the most common cause of septal perforation. Factors predisposing to septal perforation include devascularized mucosal flaps (dissection is performed in the wrong plane), bilateral opposing mucoperichondrial flap tears, hematoma, and infection. In order to reduce the possibility of developing perforations, it is necessary to maintain an adequate plane of dissection and repair defects with resorbable sutures. Special care during mucosal suturing and tamponade placement should reduce hematoma formation.
- Occasionally, patients may notice transient anesthesia of the palate and teeth. This is most likely due to injury to the branches of the nasopalatine nerve that pass through the incisive foramen.
- Anosmia is an uncommon complication after septal surgery and potentially occurs if the dissection is carried high in the region of the vertical plate of the ethmoid.
- More significant disruption of the structures in this region can lead to leakage of the cerebrospinal fluid (extremely rare).
Nasal septum surgery is both challenging and rewarding. A rhinosurgeon needs extensive knowledge of nasal anatomy, physiology, and pathophysiology to effectively plan therapy to relieve a patient's often wide-ranging and varied symptoms. The use of techniques and principles of nasal septal reconstruction should provide the means to consistently achieve success.