Patient complaints of airway obstruction that are consistent with intranasal physical findings often lead to septoplasty and turbinate surgery. However, some patients with huge septal deviations present with few if any complaints, and some patients with minor deviations complain the most. Treatment must be individualized. Review of the history of septoplasty provides better understanding of the terminology handed down to the younger generation of nasal surgeons and serves as a reminder of ground covered and abandoned. The techniques we use in modern surgical procedures have evolved from those that originally were less than optimal or that had unscheduled outcomes. It is interesting to note that the goal of septal surgery is the same as it was 100 years ago, but now the process has changed; the nasal surgeon still strives to maximize the symptomatic improvement of nasal obstructive complaints and minimize the risks involved in such a pursuit.
Technique Evolution The closed septal redisplacement methods described and advocated by Adams1 and Asch4 in the late 1800s relied on blunt force and attempts to disrupt cartilage attachments and inherent properties. Freer22 goes so far as to suggest that the technique involves the “…temptation to use violence to overcome the resiliency of the septum.” Asch4 was careful to advocate this method only for correction of the cartilaginous deviations and never for correction of vomer or ethmoidal bone crookedness. Asch lent his name to the forceps specifically designed to accomplish the closed reduction of this cartilaginous segment.
Although not thoroughly disappointing to all patients, Asch’s technique provided little long-term improvement for the complaint of nasal obstruction and only seemed to mobilize cartilaginous deformities by failing to specifically address the factors responsible for them. Asch certainly had good intentions and even describes the crushing and disruptive techniques and tools that he used in attempts to disrupt the intrinsic forces. However, correction of patient complaints was ultimately short lived.4 Asch’s technique, which was widely abandoned around the turn of the century, perhaps provided a base from which the closed bony nasal reduction procedure takes root. Few today will even attempt septal redisplacement after injury and certainly not consider it as a primary corrective maneuver for the complaint of nasal obstruction, simply because of lack of efficacy.
Kreig54 described a technique of mucosal resection in which the deflected cartilaginous segment, along with overlying mucosa, was removed in its entirety; this left a large perforation and caused other complications that surely outweighed any temporary benefits. Follow-up notes for patients who had undergone the mucosal removal procedure may have included descriptions of crusting, bleeding, and worsened nasal obstructive complaints. The increased obstructive complaints may have even provided insight for nasal researchers during this timeframe and may have led to baseline research of nasal flow principals and, ultimately, the description of laminar and turbulent airflow dynamics as discussed by Proetz68 and further refined by Fomon and colleagues.20
Krieg would ultimately suggest mucosal preservation and removal of only the deflected cartilaginous segment, which probably gave rise to the more prevalent submucous resection procedure still practiced by some today. Freer22 gives credit to American researcher and surgeon E.F. Ingals in 1882 for the description of mucosal flap elevation and removal of a triangular portion of the quadrilateral cartilage. This was the so-called “window resection.” Krieg54 described resection of the entire deflected cartilage segment and used a slightly different mucosal incision. Boenninghaus8 suggested that resection be continued more posteriorly into the vomer and perpendicular plate of the ethmoid, if necessary, for definitive airway straightening.
Overall, little emphasis was placed on the potential structural support that the septum afforded. In fact, many, including Freer22 and Fomon and colleagues,20 felt that the overlying mucosa was the only physiologically important structure within. Saddling of the nose was blamed not on cartilage resection but rather on the cicatricial forces of healing.
As nasal anatomic nuances and physiologic properties have become better understood, surgical correction for the problem of nasal obstruction has also evolved. The role of the septum as a determinant of nasal shape and contour has been recognized.26
Correction of Cartilaginous and Bony Septal Obstruction Techniques used today are still geared towards septal resection, but more emphasis has been placed on preservation, realignment, or a combination of the two. Indeed, the term septoplasty takes its meaning from the Greek term that means “to reshape or mold the septum.” Most standard procedures today recognize mucosal preservation as a primary goal and make use of a submucous cartilaginous and bony approach. Chapter 44 The Nasal Septum 11
Anesthesia and Analgesia
The operator must use topical and local vasoconstrictive anesthetic for not only the analgesic qualities but also, more importantly, for the vasoconstrictive effects. A dry operative field allows the surgeon to carefully dissect the lining away from the deviated cartilage or bony septum so that resection or reshaping can take place. The most popular topical solutions are 4% cocaine or 2% Pontocaine mixed with 1% ephedrine or 1% Neo-Synephrine. Before placement of these topical agents into the nose, preoperative treatment by the anesthesia team with fentanyl and versed acts as a stabilizer for cardiac and smooth muscle. These agents counter the potential increase in heart rate or blood pressure that is sometimes seen. With the use of 2 to 4 mL of 4% cocaine solution or 1 mL of the 2% Pontocaine solution on cotton pledgets, toxicity is rare. If local and intravenous sedation make up the chosen anesthetic path, the chance of toxicity may be more, because this option relies more heavily on the local analgesic properties of the topical and local medicines. Systemic toxicity from these topical solutions is marked by constriction of the pupils, hypotension, vomiting, and cardiac or respiratory arrest. The ability to assess for toxicity depends on the plane of anesthesia and requires close surveillance. Administration of 100% oxygen— along with use of a ventilator for respiratory support and the administration of vasopressive and or cardiotropic medicines—may be required while these agents are naturally metabolized by the patient’s body. The older or pediatric patient is best served by minimizing doses. For the patient with cardiac issues or for cardiac hypersensitivities seen in patients with a past or present history of drug abuse, local injection for anesthetic effects and oxymetazoline (Afrin®) for vasoconstrictive purposes may be more appropriate. Our injectable anesthetic of choice for the otherwise healthy individual 1% Xylocaine with 1:100,000 epinephrine used with a maximum suggested dose of 4 to 7 mg/kg based on the Xylocaine content.
The local injection is performed with either a 27or 30-guage needle and has a second useful purpose in that it will further ease identification of the correct dissection plane as a result of its hydrodissective qualities. The injection is started at the caudal end of the septum, and secondary injections are performed more posteriorly until the mucosa is well blanched or maximum volume based on patient weight is met. The contralateral membrane should also be injected, and so should the area of the nasal floor around the maxillary crest. After the injection is performed, waiting at least 10 minutes ensures maximum vasoconstriction.
Incisions and Plane of Dissection for Septoplasty
The Killian incision,46 which was described and published in the early 1900s, is one that is created approximately 1- to 2-cm posterior to the caudal septal margin within the respiratory epithelium. Some surgeons were taught this incision and still find it very useful when septal deviation is only found in the middle to posterior third of the nasal cavity. Its greatest downfall, however, is in its relative inaccessibility to the caudal septal edge and the higher potential for membrane tearing as a result of its location within the delicate respiratory lining.43
By contrast, the hemitransfixion or transfixion incision made at the caudal border of the septum allows access to the deviated caudal septum and any posterior deflections. The incision is created within the squamous epithelium of the vestibule and hence has less of a tendency to tear under stressors. Although the hemitransfixion incision is ideal in most scenarios, conversion to a full transfixion incision is easily accomplished by incising completely through to the opposite membrane (Figure 44-12). Some may still approach the septum through an open rhinoplasty approach using marginal and transcolumellar incisions. In the open approach to the septum, the medial crura are separated, and the caudal septum is then identified. Even more so than with the full-transfixion incision, tip support is significantly weakened with this open dissection technique, and so the authors reserve this approach for those undergoing an open approach to septal perforation repair or in complex cases when using an external approach to rhinolasty. Even then, tip support should be reconstituted to prevent future tip ptosis at the completion of the procedure.48
Figure 44-12. A, Schematic showing the Killian incision and the hemi-transfixion incision. Note the incision placements relative to the caudal end of the septum.
The hemitransfixion incision decreases tip support to a minimal degree, and, for this reason as well as for the access it affords to the caudal septum, the hemitransfixion incision is used almost solely in our practice. It is created by first identifying the caudal end of the septum itself. Inserting the nasal speculum into the nose and gently retracting the slightly opened speculum clearly reveals the caudal septal edge. The No. 15 blade is then used to incise mucosa down to and through the perichondrium. Identification of the proper plane is now of utmost importance. Dissecting within a subperichondrial plane ensures little bleeding and a hardier flap with less likelihood of perforation. “Scraping” the cartilage at the incision site to denude any hint of perichondrium before initiation of the elevation process helps to ensure the proper plane.
The Cottle elevator, with its two dissecting faces— one shaped like a sharpened spade and the other more flat and dull—is still used to raise the envelope under direct vision. The sharper spade-like end is used first to begin the dissection in the submucoperichondrial plane. After the dissection is started, the flat and dull end efficiently elevates the envelope in an atraumatic fashion. The surgeon should elevate the envelope with a wide front to ensure the best visibility and decrease the risk of mucosal tearing. Some surgeons prefer the Freer elevator with its straighter dissecting face, but caution is suggested because of the increased ease of perforation through the membrane (Figure 44-13). Advantages of the Cottle elevator over the Freer are because of its two dissecting faces.
Figure 44-13. The Cottle and Freer Elevator. Note the two faces of the Cottle instrument, one spade like and the other more blunt. The spade end is used to initiate the separation of between the microperichondrium and the cartilage; once the flap is raised anteriorly, the blunt end is used to elevate posteriorly. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Addressing the Deflected Cartilaginous and Bony Septum Proper: Basic Technique
Having created the incision and begun the elevation of the mucoperichondrium, longer speculae are used as the dissection proceeds posteriorly. Before advancing posterior to the bony-cartilaginous junction, elevation of the mucoperiosteum along the nasal floor is frequently necessary to address any maxillary crest deviation or to address the septum that has shifted off of the crest and is found to be obstructing the inferior airway. Identifying the pyriform rim, scraping along the bone to ensure that one is under the periosteum, and then elevating the mucoperiosteum along the nasal floor accomplishes the floor dissection. By elevating above the crest or deviated floor segment and then elevating below the segment, the surgeon creates two pockets or tunnels. Incising the nasal floor deflection or connecting the two tunnels directly helps to avoid mucosal tears during the envelope elevation phase of the procedure. The dissection may be eased with the use of the sharper spade end of the Cottle ele vator. The surgeon will find the transition from mucoperichondrium to mucoperiosteum to be a difficult dissection, and tearing the mucoperichon drium may be unavoidable. Any tear in the membrane is repaired with 5-0 plain suture, and, if bilateral membrane wrents are noted, not only should they be repaired, but an interposition graft of crushed car tilage should be placed. This interposition graft will significantly decrease the chance of permanent perforation.
Figure 44-12, cont’d B, The Cottle elevator is inserted in a subperichondrial pocket and the flap is elevated.
The dissection continues past the bony-cartilaginous junction to gain access to any posterior bony deflection or spur. At this time, the Cottle elevator may be used to separate the bony and cartilage septal segments, which is helpful if a posterior septal bony deflection is a primary issue. Separation at the juncture allows bilateral posterior septal membrane elevation. A septal spur or a projection of either cartilage, bone, or a combination of both is frequently seen at the bony-cartilaginous junction. Bilateral membrane elevation followed by septal incision using a Becker septal scissor above and below any deviated septal segment or spur allows increased mobility of the deflected segment. The nasal speculum can then be used here to push the crooked incised segment medially or laterally and, in so doing, the mucoperichondrial flaps can be more easily elevated, thereby giving reasonable assurance that membrane perforation will be minimal. It is in the area of a spur that the risk of membrane fenestration is greatest. The risk is increased because of the difficulty of membrane release and the frequently thinned overlying membrane. We avoid the Jansen-Middleton forceps for cartilage removal, preferring instead the wide-mouthed Watson-Williams forceps, which have less risk of cutting the cartilage that may be required for nasal grafting later in the procedure. To prevent cribriform plate injury, the superior bony septum is never manipulated without first performing a superior septal incision or cut. Even then, any posterior septal removal is done within one rotational plane.
Having addressed the posterior septum, the surgeon turns his or her attention to the cartilaginous septum, including the caudal end and the floor segment. To decrease the potential for loss of dorsal or tip support, the surgeon preserves at least a 1-cm dorsal and 1-cm caudal septal segment, which has been termed the L-strut67 and is inclusive of the nasal spine. Preservation of the L-strut is perhaps the base upon which most surgeons work (Figure 44-14). Resection of a large central septal segment can be done safely, if required, to address central septal deflections or if grafting materials are needed for rhinoplasty. After the membrane is elevated from at least one side, the sharper beveled edge of the Cottle elevator can be used to incise the cartilage. The incision is started at the bony-cartilaginous junction by gently penetrating the cartilage with the Cottle elevator. The incision is carried forward and deflected inferiorly, thus preserving the 1-cm dorsal and caudal support segment. Contralateral septal membrane is elevated with the freeing of the inferior-most aspect of the septum from the maxillary crest trough with gentle blunt dissection. If the floor is deviated, creating an incision on the deviated segment and then using the two-tunnel approach as described above for the floor deviation proper provides another method for membrane elevation. Removal of the freed segment with a nonbiting forceps completes the resection. A No. 15 blade can be used for the cartilage incision but may result in contralateral membrane injury if one penetrates the contralateral perichondrium. The Ballenger swivel knife is an older septoplasty instrument that is sometimes used, but it has a propensity to tear membrane and over-resect septal cartilage.
Figure 44-14. Schematic showing the 1 cm caudal and dorsal segment that should be left intact so as to provide tip and dorsal nasal support (L-strut.)
One of the more frequently seen septal deviations occurs when the quadrilateral cartilage has shifted laterally off of the crest or there is deviation of the crest itself; this leads to nasal floor obstruction. Explanation for this occurrence may be found in the patient’s history of early trauma with crest fracture or may simply be due to cartilage growth and a shallow groove of the maxillary crest (Figure 44-15). Correction of this problem requires bilateral membrane elevation, with extension of the membrane elevation along the nasal floor. The Cottle or the No. 15 blade can then be used to excise the deviated cartilaginous component, and a 4-mm unguarded osteotome is used for any bony contribution. The nasal spine is preserved in almost all scenarios. After the inferior floor segment has been excised, a superiorly based swinging door is created (Figure 44-16). The now-mobile septal segment is then relocated to the maxillary crest groove, and the anterior most aspect is secured to the periosteum of the maxillary crest or spine with 5-0 long-lasting absorbable suture. This maneuver should be used as a primary step for straightening the extremely bowed septal segment, especially when the external nose is also deviated. If the obstructing maxillary crest segment is limited to one side, the deviation is tangentially shaved with a 2-mm osteotome placed parallel to the crest; this allows for improvement of the nasal airway without any loss of otherwise normal crest support. Bowing in the high anterior septum that is not adequately corrected by freeing the segment from the crest attachments can be addressed in a number of different ways.
Figure 44-15. A, Schematic showing the relationship of the trough of the maxillary crest and the inferior aspect of the septum. B, Schematic showing the inferior aspect of the septum shifted from a crest which is also deviated and needs to be reduced.
Figure 44-16. A deviated septum that is off to the side of the maxillary crest must be separated from the bony perpendicular plate; the inferior cartilaginous portion must be trimmed so it can be slid back onto the crest by swinging it back to the midline, basing its attachment superiorly. Once back into the midline, the caudal end is sutured to the periosteum of the maxillary crest to maintain its position. If a caudal deviation is also present, a tongue-in-groove maneuver may also be necessary by placing and sewing the caudal end of the septum in between the medial crura.
In any area in which the cartilage is thick (e.g., near the dorsum at the bony-cartilaginous junction), tangentially shaving cartilage with the No. 15 blade may provide improvement without structural change. Other options may be to crosshatch or score the deviated segment or to excise a full-thickness cartilage wedge (i.e., as is done with a septal fracture) (Figure 44-17). Finally, a straight cartilage graft can be placed along the dorsal deviation between the septum and the upper lateral cartilage to combat bowing of the high anterior septum. The graft, which is fashioned from harvested septal cartilage, is sewn in place with 5-0 polydioxanone in a horizontal mattress fashion. This is easily accomplished through an external rhinoplasty approach; however, a closed approach may also be used (Figure 44-18). Having addressed the deviated cartilage, septal spur, and deviated maxillary crest, the cartilage that is not to be used for another purpose (e.g., grafting in rhinoplasty) is crushed and placed back into the membrane pocket for reskeletonization of the flaps. Postoperatively, septal flaps without interposed cartilage adhere to one another without supporting structure; these weakened flaps are susceptible to injury and potential perforation, especially if there are contiguous membrane fenestrations. Placing crushed cartilage back into the envelope serves as a barrier for perforation development, prevents motion of the membrane with inspiration or expiration, and allows easier reentry if another procedure is required.
Figure 44-17. Schematic demonstrating wedge excision of septal fracture or deviation.
Figure 44-18. Schematic showing unilateral spreader graft placement for septal straightening.
After reskeletonization, the entire septal flap from anterior to posterior is mattressed with a continuous 5-0 plain stitch; a curved needle (instead of the popular straight Keith needle) should be used for this purpose. Using a curved needle during the mattressing procedure decreases the potential for lateral nasal wall or turbinate injury, thereby decreasing formation of intranasal synechiae. The mattress suture secures the cartilage replacement grafts in place, re-coapts the elevated mucoperichondrial membrane, and prevents hematoma.31,70 To prevent future perforations, any identified fenestrations in the septal lining—even unilateral fenestrations over the segment—are closed with 5-0 plain suture at the time of septoplasty. Wrents in the membrane are most likely to occur in proximity to a septal spur or a severely deviated septal segment due to the difficulty of dissecting or due to thinned mucous membrane over the segment. Sometimes, as indicated above, the spur is so large and the membrane is so thin that a perforation is unavoidable. The key is to prevent contiguous bilateral mucous membrane fenestrations, close them if they occur, and always interpose a crushed cartilage graft for added support.
The hemitransfixion incision is also closed with 5-0 plain stitch. Care is exercised when tying the individually interrupted sutures so that suture cutting of the alar facet does not occur at the alar rim apex. When the stitch is pulled cephalad during tying, it can easily cut the alae, thereby leading to long-term deformity or fissuring in this area (Figure 44-19). This alar deformity is extremely difficult to correct and rarely heals because of chronic bacterial colonization.
Figure 44-19. A non-healing fissure of the skin of the apical nostril can be caused by rubbing sutures against the skin while tying intranasal knots. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Septoplasty and the Caudal Septum
Employing methods of repositioning and fixation of the caudal septum rarely make it necessary to aggressively trim or excise this segment (Figure 44-20).78 The deviated inferior edge of the septum (which has shifted from the crest) and the truly dislocated caudal margin are first addressed by bilateral mucoperichondrial elevation.
Figure 44-20. Photo showing the widened columella created by caudal septal deviation which additionally pushes the medial crura into the airway. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
After the septum along the floor and the crest are straightened as described above and the swinging door created, the length of the septum is evaluated. If the septum is long, a conservative trim is warranted. Otherwise, the caudal margin can be replaced to the midline nasal spine, secured, and sandwiched within a pocket created between the medial crural footplates. A columellar-septal mattress suture of 4-0 chromic is passed transcutaneously and holds the caudal septal margin and medial crura in place. This maneuver, which was first described by Rethi71 in 1934 and later by Fred21 in 1950 was repopularized and named the tongue-in-groove maneuver by Kridel and colleagues53 in 1999; it provides a midline fixation technique and helps to make caudal septal trimming less necessary (Figure 44-21). If the caudal septum is significantly gnarled (which contributes to a hanging columellar appearance) or extremely deviated, it can be trimmed or excised. If the caudal septum is removed or significantly trimmed, it must be replaced with a septal reconstruction graft.52 Tip ptosis occurs when the caudal septum is over-resected as a result of interference with two of the four recognized tip-support mechanisms described by Janeke and Wright.41
Figure 44-21. Schematic showing the tongue in groove technique marked by interposition of the caudal septum between the feet of the medial crura.
Septoplasty with Caudal Absence and Tip Collapse: Septal Reconstruction
Unfortunately, overaggressive resection of the caudal septum is still performed. Tip ptosis, retraction of the lower aspect of the columella, and widening of the alar base are characteristic findings of aggressive caudal septal trimming. Although there certainly are indications for caudal septal trimming, we limit this practice to only those cases in which the septum is so crooked it cannot be straightened or so long that it pushes the columella down and can be palpated between the medial crura (Figure 44-22). Description and explanation of the caudal septal replacement procedure is beyond the scope of this chapter, and so the reader is referred to an article by Kridel and Lunde.52
Figure 44-22. A, Patient with loss of projection and tip ptosis second to overaggressive resection of the caudal septum. B, Patient after caudal septal replacement. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Septoplasty Combinations: the Rule and not the Exception
Approximately 20% to 30%17,30,65,80 of patients who undergo septoplasty find that their symptoms are not corrected adequately. A subset of these patients may undergo reoperation in an attempt for definitive correction. Partial explanation for the requirement for reoperation may be found in the inherent memory that cartilage possesses or in the requirement to end septal correction surgery when support of the nose is at risk for compromise. In the patient with a severely deviated septum, preoperative discussion should focus on the improvement of nasal obstructive complaints and not perfection. The failure rate may also suggest that we, as nasal surgeons, are not looking actively enough for other contributors to this subjective complaint. Obstruction as a result of internal valve compromise is most often an issue in the patient with a narrow middle third of the nose as seen, for example, in the patient with the typical tension septum.76 Such a patient has an increased nasal dorsal height or hump that narrows to the nasal bridge and a tethered appearance to the upper lip (Figure 44-23). Others with valve compromise may have high septal bowing into this area, inferior turbinate hypertrophy, or a paradoxic inferior conchal curve. The patient may also have had a rhinoplasty, in which case the upper lateral cartilages were either not reattached to the septum or the ULCs were mobilized from their attachments beneath the nasal bones, with subsequent inferior ULC displacement. This inferior displacement or replacement at a lower level creates an “inverted V ” sign externally and a narrowed valve angle intranasally (Figure 44-24). Identification of the patient with internal nasal valve collapse should be done before surgery so that the procedure can include enlarging this angle.
Figure 44-23. Photograph of the typical patient with a tension septum. In such a patient, the cartilaginous dorsum projects above the dome tip cartilages, tents up the soft tissue of the nose, narrows the middle third of the nose, and causes a tethered appearance to the upper lip. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Figure 44-24. Photograph of a post-rhinoplasty patient with an “inverted V” sign seen secondarily to descent of the upper lateral cartilages or improper replacement post-rhinoplasty. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
The external valve plays a large role in airflow regulation. External collapse occurs as a result of previous nasal surgery in which the LLCs were over resected or morselized to the point of losing their sup- portive function or as a result of the natural aging process, in which the scroll between the ULC and LLC begins to unfurl. Preservation of an adequate strip of intact LLC ensures that the external nasal valve area retains adequate support.49 The amount of in situ car- tilage that should remain depends on the nature of the cartilage, the thickness of the patient’s skin, and the tip dynamics (e.g., projection, rotation).
Low inferior osteotomies that sacrifice the side wall support fibers or osteotomy techniques that denude the nasal bones of the periosteum can also decrease the support of the lateral nasal wall, which results in lateral nasal wall collapse with breathing. Discussion of past surgical history with the patient is important. Observing the side wall motion during restful breath- ing and during forced inspiration allows the surgeon to evaluate for external valve contributions to nasal obstructive complaints. Although a Cottle maneuver may be helpful in those patients with a history of pre- vious surgery, a false-negative Cottle maneuver is pos- sible if scar banding from the septum to the lateral nasal wall is present. False positives with the Cottle maneuver are also likely, and so lateral displacement. of the ULC is a better predictor of whether valve surgery would be warranted.
Septoplasty with Correction of the Nasal Valve
If valve grafting is required, preoperative planning should allocate cartilage harvest for this purpose. The harvested septal cartilage can easily be fashioned into spreader grafts for stenting of the internal nasal valve angle or batten grafts for bolstering the valve area (i.e., an external nasal valve). Internal valve reconstruction requires separating the ULCs from the dorsal septum, thereby freeing up the attached mucoperichondrial septal membrane from the medial surface of the ULC so that the membrane remains in the nasal cavity and not sandwiched into the dorsum, where it later may swell
(Figure 44-25). The cartilaginous graft is inserted into the space between the septum and the ULC and thereby widens this space by lateralizing the ULC and opening the angle. The graft is secured into place using a horizontal mattress 5-0 absorbable suture. By releasing the ULC septal membrane inferiorly, the suture can be passed through the ULC, the graft, and then the septum (Figure 44-26).
Figure 44-25. Spreader grafts are placed between the septum and the upper lateral cartilages to widen the internal nasal valve angle and correct nasal obstruction. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Figure 44-26. Schematic showing the spreader grafts interposed between the septum and upper lateral cartilages with the septal membrane released inferiorly. A horizontal mattress suture attaches the upper lateral cartilages, spreaders, and septum together
Placing a spreader graft from an endonasal approach is more technically difficult; it is accomplished by first completely elevating the septal membrane up to the nasal dorsum, especially in the area of the valve. Next, the membrane from the medial aspect of the ULCs is teased from its attachment there. Securing the spreader graft is best done by re-coapting the mucoperichondrial membrane and septum inferior to the graft with a through-and-through 5-0 plain quilting stitch.
Sewing the graft in place is optimal fixation for ensuring that there is no inferior displacement into the septal pocket. External valve grafting (i.e., correction of the valve area as opposed to valve angle) is helpful in those patients with obvious lateral nasal wall collapse with Chapter 44 The Nasal Septum 21 inspiration. Placement of the batten graft is generally performed from an open approach, because the majority of patients with external valve compromise also have a history of previous rhinoplasty or nasal surgery.83 Cartilage is fashioned into 5- to 6-mm × 1.5- to 2-cm battens, placed cephalad to the remaining LLC, and extended laterally across the pyriform rim. The batten maybe secured to any remaining LLC with 6-0 Prolene in a mattress-stitch fashion. The graft literally acts as an “umbrella” and holds the lateral nasal wall in place, overcoming the Venturi effects elicited by inspired air. If previous surgery resulted in the removal of the majority of the LLC, the batten can be used directly as an LLC replacement graft by securing it to the middle or medial crural remnants and allowing it to extend laterally. This replacement graft, in addition to providing support to the nasal side wall, will improve the pinched-appearing nasal tip by creating a more uniform tip (Figure 44-27). In the patient with a history of low to high osteotomies in which the pyriform triangle and the fibrous support to the lateral nasal wall are absent, graft placement must extend laterally across the pyriform rim to hold the alae and lower nasal third laterally and, in so doing, correct the collapse. Extending the graft across the rim is done by gently creating a subcutaneous tunnel that extends over the rim below. Performing an osteotomy in a patient with lateral wall collapse is to be done judiciously, because this may weaken the remaining in situ support even more.
Figure 44-27. Intraoperative photograph showing alar batten placement technique to the lower lateral cartilages designed to strengthen the external nasal valve. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Other methods for improving the valve angle and area are those that make use of suture or other techniques to manipulate in situ cartilage structures.58 Park63 writes of his experience with nasal flaring sutures, which are 4-0 sutures that are placed through the inferior-lateral edge of the ULCs bilaterally and tied across the nasal dorsum. The dorsum acts as a fulcrum, and the internal valve angle is subsequently opened. His studies suggest that the use of spreader grafts with the flare suture provide the most benefit for the internal valve compromise correction. In a similar fashion, patients with a concave ULC or LLC may benefit from a permanent Mustardé suture through the cartilage itself that changes a convex curve to a concave one and, in so doing, opens the angle, thus creating a greater intranasal cross-sectional area. The operator may also “flip and reverse” the concave LLC and then secure it back into position. Finally, aggressive scoring of the LLC may release the intrinsic shape, but, because of unreliability and the risk of weakening support of the nasal side wall, it is better to avoid this technique if at all possible. Recent writings by Paniello62 and Park63 suggest valve area suspension from laterally placed periosteal sutures as a last effort for the refractory external valve collapse.
Septoplasty with Septal Perforation Repair
Septal perforation has been a recognized potential complication of septoplasty and should always be included in preoperative disclosure discussions of surgical procedure risks. Prevention of septal perforation begins with techniques that include immediate intraoperative closure of any fenestrations, meticulous membrane elevation within the appropriate subperichondrial plane, and reskeletonizing the septal membrane pocket with crushed septal cartilage. A perforation creates changes in the airflow pattern; this change from laminar to turbulent flow results in the crusting of naturally produced mucous. Nasal mucosa drying, bleeding at the perforation edge, and a whistling noise with nasal breathing are sure to follow. Long-term sequelae in patients with untreated perforations as a result of a loss of septal support can include saddling of the nose81 and tip ptosis (Figure 44-28). Ignored and untreated perforations can ultimately produce chronic low-grade infection with resulting osteitis of the bony septum or of the nasal floor or side walls.
Figure 44-28. Photograph of a patient with a large central septal perforation and secondary nasal saddling. To view this image in color, please go to www.ototext.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
Almost all current literature supports septal perforation closure with intranasal flaps and connective tissue interposition grafts. Our preference is a procedure that is performed through an external rhinoplasty approach with nasal floor advancement flaps and an interposition graft of temporalis fascia or acellular human dermis.48,60 The detailed description of this procedure is beyond the scope of this chapter, and so the reader is referred to references cited.
Septoplasty and Rhinoplasty: the Combined Procedure
Septoplasty frequently plays a role during rhinoplasty surgery to either correct obstruction or to harvest cartilage to be used as possible graft material. The surgeon is wise to remember that making a nose smaller by narrowing the dorsum with osteotomies, retrodisplacing the nose via a lateral crural overlay technique, or narrowing the alar base ultimately increases nasal resistance through decreasing cross-sectional area. Ensuring an open and straight inside nose may decrease the likelihood that nasal obstruction will become a patient complaint postoperatively, when the nose is made smaller. If shaving of a nasal hump is planned, the surgeon must take into account the septal contribution to this hump. A conservative septoplasty with attention to the preservation of a more-than-adequate dorsal strut will decrease the risk of a loss of dorsal cartilage support (Figure 44-29).
Figure 44-29. If a high septal deviation extends to the cartilaginous dorsum and one attempts to remove the full deviation, the dorsum might saddle, especially if a concomitant rhinoplasty with osteotomies is performed.
Rarely does making a hemitransfixion or a full transfixion incision and then using an open rhinoplasty technique that includes the marginal and columellar incisions lead to tissue compromise. A disadvantage of approaching the septum solely through an open external approach (as we do for a septal perforation repair procedure) is in its disruption of the support mechanisms of the nasal tip. Reconstituting these support structures at the end of the procedure is necessary to prevent tip ptosis or unwanted rotational changes.
In the nose with a deviated dorsum, the septum is frequently responsible for the crooked appearance. Septoplasty should include bilateral release of the ULCs from their attachments to the dorsal septum, which is done by elevating the septal membrane from the septum up into the area of the internal valve and followed by the careful insertion of the No. 15 blade into the pocket and releasing the ULCs from their dorsal attachments. This maneuver will oftentimes release intrinsic cartilage forces and both improve nasal airway patency and accomplish dorsal straightening. Occasionally a single spreader graft (as indicated earlier) can be inserted at the point of greatest septal bowing to act as a straightening crutch. The spreader is attached as described. Ultimately, reattachment of the ULC to the dorsal septum at the completion of the rhinoplasty procedure is imperative to prevent additional nasal valve angle compromise.
Finally, osteotomies must be performed by preserving the periosteum and the inferior pyriform fibrous attachments. Avoiding lateral periosteum elevation before osteotomy and preserving an inferior triangle of pyriform bone28 >effectively preserves the cartilaginous and soft-tissue attachments, thereby making external nasal collapse less likely. Rarely is there occasion to make the osteotomy in a low-to-high fashion, which is in contrast with our favored method, the high-to-low-to-high bony cut (Figure 44-30).
Figure 44-30. A favored high to low to high osteotomy technique effectively preserves the pyriform triangle and the fibrous attachments of the nasal sidewall.
Some surgeons use an endoscope during mucoperichondrial elevation for better visualization23,36; the increased vision in a dry operative field may help some prevent mucosal tearing when deviations are acute. The CO2 laser has been used to selectively excise septal spurs; however, this is not our preferred method. Mucoperichondrium and the cartilaginous spur are completely excised, with the laser taking no more than 2 to 3 mm of vertical height to permit mucosal healing and closure; the opposite mucoperichondrium is left intact.42 The laser has found other uses in the nose, ranging from ablation of intranasal papilloma61 to turbinate reduction procedures.47