The nasal septum is a structure poorly understood and appreciated by the lay public and the nonotolaryngologist—head and neck surgeon alike. Deviation of the caudal portion of the nasal septum may result in nasal obstruction, a crooked nose, and columellar irregularities. The correction of a severely deviated caudal septum is one of the most difficult challenges of the otolaryngologist and facial plastic surgeon. A variety of options are available for correction of mild, to the most severe, deflections. This condition, as with all challenges in medicine, should not be a one size fits all or one surgery fits all situation. The skilled surgeon should understand the multiple options available for surgical correction and tailor fit the procedure to the deformity.
The deviated nasal septum is recognized as a source of nasal obstruction, crusting, epistaxis and recurrent rhinosinusitis. Although the ideal nasal septum would be a straight midline structure in the sagittal plane, most individuals have some degree of curvature or irregularity of the nasal septum. The etiology of a deviated septum is generally congenital, but may also be as a result of trauma or iatrogenic causes. A curved or deviated nasal septum becomes clinically significant when it results in functional or aesthetic morbidity.
Patient quality of life is most often affected when the curvature of the septum results in nasal obstruction. Deviation and obstruction can occur at any point of the bony or cartilaginous septum. Small changes at the dorsal septum can significantly narrow the internal nasal valve, which can further result in dynamic collapse of the upper lateral cartilages. Deflections of the caudal end of the septum result in direct airway obstruction at the nasal vestibule and further congestion caused by tip ptosis and airway collapse.
Aesthetically, nasal septal irregularities can result in twisting of the nose, dorsal humps or depressions, and underprojection. The caudal septum provides a unique set of challenges to the rhinologic surgeon. Unrepaired caudal deviations can cause twisting of the lower third of the nose. Crooked or absent cartilage at the caudal end will also lead to loss of a major tip support mechanism. This can lead to underprojection of the nose and tip ptosis. Finally, the deviated nasal septum can result in columellar irregularities.
Septoplasty, with or without turbinate reduction, is perhaps the most common surgical procedure to address persistent nasal obstruction. Simple submucosal resection of bony or cartilaginous deviations of the midseptum is a technically uncomplicated and highly successful operation. Control of the dorsal septum often requires separation of the upper lateral cartilages and placement of spreader grafts to open and maintain a satisfactory valve angle. It is essential that an appropriate caudal and dorsal strut is left intact to maintain stability of the middle and distal third of the nose. It is commonly accepted that leaving between 1 cm to 1.5 cm is sufficient to maintain support. Loss of this strut, whether through trauma or over-resection can lead to tip instability, valve collapse, and undesired aesthetic alterations of the external nose.
Deflections of the caudal end of the nasal septum are often not addressed at the time of primary septoplasty because of fear of disrupting the caudal strut. By avoiding the caudal strut, the 600 pound elephant in the corner, surgeons are limited in their ability to treat the functional and aesthetic complications of many septal deviations. Satisfactory treatment of the caudal septal deviation requires the surgeon to have a mastery of the complex anatomy of the nasal support structures, an understanding of the options available for treatment, and the ability to execute an appropriate treatment strategy ( Fig. 1 ).
Anatomy
The nasal septum is a bony and cartilaginous structure which separates the nasal cavity into two halves. It also stabilizes the upper and lower lateral cartilages and is a major tip-support mechanism.
The anterior and caudal extent of the septum is cartilaginous. This quadrangular cartilage forms attachments cranially, at the osseous septum, and inferiorly, at the maxillary crest. The maxillary crest terminates anteriorly at the nasal spine. Firm attachments anchor the posterior septal angle of the quadrangular cartilage at this point. A mucoperichondrial flap covers the cartilaginous septum bilaterally, supplying added support and a vascular supply to the underlying cartilage.
Dorsally, the cartilaginous septum is connected to the paired upper lateral cartilages. These cartilaginous structures are fused in the midline and form the internal nasal valve. Caudally, the cartilaginous septum is connected to the lower lateral crura by the intercrural ligament. This fibrous attachment provides additional tip support.
The cranial and posterior septum is primarily osseous. In many patients a small strip of cartilaginous septum extents posteriorly between the perpendicular plate of the ethmoid and vomer.
The perpendicular plate of the ethmoid extends along the posterior and superior extent of the septum in the sagittal plane. Superiorly it attaches to the nasal bones, frontal bones and the cribriform plate. Care should be taken when correcting a posterior septal deformity to not disturb the thin attachments to the cribriform plate and risk a CSF leak or injury to the olfactory nerve.
The inferior extent of the osseous septum consists of the vomer. This unpaired bony structure rests on the maxillary crest and forms the midline partition of the nasal choanae ( Fig. 2 ).
History
Attempts to correct nasal septal deformities were described in the medical literature as early as the late 19th century. Early techniques included septal splinting, fracture, and excision. Elaboration of these methods led to excisions that included the vomer, perpendicular plate of the ethmoid, and accompanying mucosa. These techniques were soon abandoned because of the resulting functional and aesthetic morbidity.
Killian and Freer began advocating a more conservative submucous resection at the turn of the century. They emphasized the importance of maintaining the natural mucosal covering as well as leaving a structural strut in place. These early principles have formed the foundation of modern septoplasty.
History
Attempts to correct nasal septal deformities were described in the medical literature as early as the late 19th century. Early techniques included septal splinting, fracture, and excision. Elaboration of these methods led to excisions that included the vomer, perpendicular plate of the ethmoid, and accompanying mucosa. These techniques were soon abandoned because of the resulting functional and aesthetic morbidity.
Killian and Freer began advocating a more conservative submucous resection at the turn of the century. They emphasized the importance of maintaining the natural mucosal covering as well as leaving a structural strut in place. These early principles have formed the foundation of modern septoplasty.
Medical management
Medical management of nasal congestion is generally the first line of treatment. Although anatomic abnormalities may exist, hypertrophied nasal mucosa may result in symptoms of nasal obstruction. Treatment with topical nasal steroid sprays can improve airflow and eliminate the need for operative intervention in a minority of patients. The control of inflammatory disease, such as allergic rhinitis or chronic rhinosinusitis, should be maximized before elective septoplasty surgery is recommended.
Surgical treatment
Modern surgical septoplasty generally revolves around a few core principles. A submucous approach provides a safe and effective approach to the bony and cartilaginous septum. Care should be taken to identify a precise subperichondrial pocket and maintain this plane of dissection. Surgical resection of the bony and cartilaginous septum may occur without compromising the support and shape of the external nose as long as a 1-cm dorsal and caudal strut is left intact.
The caudal septal deviation can be classified as mild, moderate, and severe. No single method of correction has been shown to be effective in all cases. Most methods of addressing the caudal nasal septum can be classified as either cartilage reshaping procedures or septal reconstruction maneuvers. Although all methods can be approached through either an endonasal or external approach, most caudal septal reconstruction maneuvers are more easily accessible by way of an external approach.
Cartilage reshaping
Septal Repositioning
Metzenbaum is credited as being the first to address the challenges of the caudal septal deviation. His paper, published in 1929, documents a swinging door method of cartilage repositioning. He describes removing a vertical wedge of cartilage on the convex side of the deformity. The anterior septum is then repositioned in a swinging door like manner and secured.
Many have used modifications of this technique in the last 80 years. Pastorek describes a simple and effective modification of this technique. After excising the vertical wedge of septal cartilage, he repositions the septum to the other side of the anterior septal spine. He describes the use of the septal spine as a doorstop to stop the septum from returning to its native position. Finally, the inferior septum is secured to the spine with a nonresorbable suture.
Translocation of the deviated caudal end to the other side of the anterior septal spine without weakening the caudal septum is an acceptable management strategy in most patients with mild to moderate caudal deviation. A recent paper by Sedwick and Simons describes using this translocation technique with excellent results. Sixty-two patients were retrospectively reviewed from a database of 2043 patients. Access to the septum was achieved by way of a complete transfixion incision and bilateral mucoperichondrial flaps. After a standard septoplasty, the deviated caudal septum was simply repositioned to the midline or contralateral side of the anterior septal spine. After translocation, the caudal end was secured to the septal spine with a polydioxanone (PDS) suture. An inferior strip was removed if the cause of the deviation was excess length. Sedwick reports that 51 of 62 (82%) patients with long-term follow-up reported no postoperative nasal airway obstruction with this technique.
Spreader Grafts
Spreader grafts have been long recognized as a method of opening the internal valve angle and gaining control over the middle nasal vault. Placement of thin grafts between the dorsal septum and upper lateral cartilages will yield consistent and predictable results. Graft material can be obtained from the quadrangular cartilage or perpendicular plate of the ethmoid.
Spreader grafts can also be extended beyond the caudal boarder of the upper lateral cartilages and used to stabilize a deviated caudal septum. Rigid bone, harvested from the ethmoid perpendicular plate, is most often used in this scenario. The long, thin bone grafts are sculpted to fit holes created for suture placement with an 18 gauge needle. Soft-tissue attachments are released from the caudal septum and the spreader grafts placed. For improved stability it is preferable that the septum be sandwiched between two spreader grafts ( Fig. 3 ).
