Septoplasty (nasal septoplasty) is a surgical therapeutic procedure in otolaryngology that can be used to treat chronic nasal airway obstruction (NAB). Septoplasty represents one of the most common surgical interventions in otolaryngology. Despite this frequent performance of septoplasty, the procedure should not be considered a standard operation because it presents a complex challenge for the surgeon. Permanent nasal airway obstruction can very often be detected during diagnostic checks. This nasal airway obstruction is due in part to the fact that a percentage of over 40 percent of the population has a deviated septum (deviation of the nasal septum) with compensatory conchal hyperplasia (proliferation of tissue as an adaptive response to the deviated septum). This deviated septum relatively often results in significant nasal obstruction. However, in addition to this epidemiologically important anatomic change, other causes may also cause nasal airway obstruction or, in the presence of a deviated septum, exacerbate the symptomatology. Other causes besides the deviated septum may include pathological adaptation processes of the glandular tissue or chronic rhinosinusitis (CRS, simultaneous inflammation of the nasal mucosa (“rhinitis”) and the mucosa of the paranasal sinuses). Furthermore, the presence of a deviated septum significantly increases the incidence of middle ear infections or disorders of the sense of smell. Furthermore, the present anatomical variations in the nasal entrance area may increase the likelihood of the occurrence of epistaxis (nosebleeds). Additionally, it can be noted that bony outgrowths in contact with the lateral nasal wall promote cephalgia (headache). Although nasal obstruction is very common in the population, it is imperative that a proper preliminary examination of the patient is performed before the surgical procedure, otherwise the success of the therapy will be significantly reduced.
Indications (areas of application)
- Septum deviation (deviation of the nasal septum) – anatomical changes of the nasal septum may be the result of previous nasal fractures. Far more often, however, the cause is a genetic predisposition (hereditary risk) or even growth impairment. Regardless of the cause, obstruction of nasal breathing is the result. Furthermore, changes in the airflow in the nose often result in additional swelling of the turbinates. Furthermore, it can be observed that the mucous membranes of the opposite side aggravate the existing deviated nasal septum. In the short term, patients may be helped by taking nasal sprays, however, due to the mechanism of action is often an unconscious increase in dose, but the consequence is that further impairment by secondary diseases such as sinusitis, tubal middle ear catarrh (wet inflammatory process of the middle ear), bronchial catarrh and cephalgia (headache).
- Nasal bone fracture – as previously described, nasal bone fractures can increase the risk of septal deviation, causing respiratory impairment.
- Chronic sinusitis – in chronic sinusitis (sinusitis lasting more than eight weeks), this surgical procedure serves to improve the drainage of secretions.
- Crooked nose due to cartilage changes – cosmetic reasons may also be an indication. However, it must be discussed with the attending surgeon whether the surgical risk for this indication is justifiable.
Contraindications
- Bleeding tendency – a congenital bleeding tendency, which may be due to hemophilia (hereditary blood clotting disorder), for example, requires special precautions to avoid serious peri- or postoperative complications. If there is still a risk, the operation must be canceled.
- Reduced general condition – since septoplasty involves general anesthesia, the patient must be physically able to compensate.
Before surgery
- Performing necessary diagnostic measures to confirm the diagnosis.For deviated septum (deviated nasal septum), nasal endoscopy (mirroring) and anterior rhinoscopy (“anterior rhinoscopy”) is the current gold standard.
- To be able to optimize the probability of success of the procedure preoperatively (before surgery), it requires various examination and preparation steps. At the beginning of the preliminary examination, it must be diagnostically clarified which surgical access should be chosen for the procedure. Here, a choice must be made between the classic incision technique and the open access route. To ensure optimal therapeutic success, it may also be necessary to deviate from the standard technique of functional septoplasty.
- After selecting the access route, it is necessary to consider the entire nasal cavity with the goal of improving nasal breathing. To achieve significantly improved nasal breathing after surgery, respiratory hypertrophy (proliferation of tissue) of the inferior turbinates must be identified. If this is the case, specific turbinate surgery should be added to the planned surgery if necessary. Of particular importance in the correction of the deviated septum is the presence of a contralateral concha bullosa (storage of air-containing cells lined with mucosa in the area of the middle turbinate, which inflate it like a balloon), since its lateral (lateral) leaf is to be resected (cut off or removed) to improve the success of therapy and the risk of this is massively increased in high septal deviation.
- Discontinuation of blood-thinning medications such as acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the treating physician. Discontinuing medication for a short time significantly minimizes the risk of rebleeding without a significant increase in risk to the patient. If there are diseases that can affect the blood clotting system and these are known to the patient, this must be communicated to the attending physician.
The surgical procedure
Septoplasty is a relatively complex procedure for the surgeon. The procedure is as follows:
- Operative access – as described earlier, the optimal access for septoplasty is determined preoperatively. However, in the majority of cases, the so-called right hemitransfixion incision is used. A special clamp, the Cottle clamp, is used to better visualize the posterior septal area. At the same time, the columella (nasal bridge) is moved to the opposite side. Following this, the incision is made behind the already exposed septal edge so that detachment of the mucoperichondrium (mucosal area that is firmly anchored to the bone) from the posterior septal edge can take place. During detachment, an appendix is created with a small pocket between the cartilage and the mucoperichondrium on the left side. However, Cottle’s surgical principle is based on not resecting bent cartilage structures of the nasal septum immediately, but on using a tissue-sparing technique to correct the anatomical deviations. This results in the advantage that existing structures can remain in the nose for further support function.
- Mobilization – crucial for mobilization is the exposure of the cartilaginous and bony parts of the supporting apparatus of the nose. To be able to perform this, at the beginning there must be a lifting of the mucoperichondrium from the cartilage. This is followed by mobilization of the cartilaginous septum by means of a straight chondrotomy (cutting of the cartilage). After the cartilage cut, the mucoperiosteum is now separated from the nasal septum, so that subsequently hereafter the septum can be straightened with the help of an osteotomy (targeted cutting of bone structures).
- Resection of cartilage and bone – in the case of lack of success or insufficient success of osteotomy, removal of bone and cartilage structures can rarely be avoided. Nevertheless, resection should be considered only as an exceptional procedure in septoplasty. In addition, the surgeon must keep in mind that both the surgical incision and the removal of the cartilage tissue must be terminated at least one centimeter below the bridge of the nose. If this minimum distance is maintained, the risk of developing a cartilaginous saddle nose and retraction of the nasal bridge can be significantly reduced.
- Reconstruction – the implementation of special reconstructive measures of the corrected nasal septum are crucial for the prevention of complications and should further lead to the absence of noticeable changes in the shape of the nose after surgery. To achieve these goals, a reimplantation of cartilage and bone is performed, so that with the help of this surgical step perforation formation and mucosal atrophy as well as the formation of a “flutter septum” occur much less frequently.
- Fixation and shape retention – for the shape retention of the nose, the focus is on the area of the anterior septum, as this is of great importance for stability. After the surgical procedure, it is necessary that the stability of the corrected septum is tested by the surgeon. Fixation of the septum is performed to improve stability. With the help of various suture techniques it is possible to further improve the stability of the septum. In addition, so-called transseptal mattress sutures can contribute to further stabilization of the reconstruction. Furthermore, splinting and nasal tamponade of the septum as the final step of the surgery help to prevent postoperative bleeding. Although, according to many clinical studies, nasal tamponade reduces the incidence of postoperative bleeding as well as hematoma and edema (water accumulation in the tissue), many scientific publications postulate that the use of nasal tamponade is not recommended or does not represent a significant advantage. Regardless, it can be stated that various types of tamponades are used depending on the surgeon’s preference and availability in the clinic. Suturing techniques also vary depending on the clinic and the treating physician. If necessary, an antibiotic may be used postoperatively.
After surgery
The nose should be treated with a sodium chloride solution and a special nasal ointment after the procedure, as the nasal mucus is highly irritated. However, it is quite difficult for the patient to take care of it, as the existing splints make it difficult to treat with a nasal ointment. The use of a special nasal oil is therefore recommended. Furthermore, antibacterial substances and possibly antibiotics should be used to reduce the infections. In addition, to reduce the rate of complications, follow-up by the ear, nose, and throat specialist within the first two weeks after the procedure is very important.
Potential complications
- Mucosal perforation – unplanned damage to the nasal mucosa may occur during the surgical procedure. Mucosal damage is the most common intraoperative complication of the procedure. Mucosal perforations occur particularly frequently in three areas of particular risk. It should be noted, however, that unilateral perforations should be sutured only if their size could allow transport of reimplanted cartilage fragments. Suturing could prevent possible aspiration of cartilage fragments.
- Hematoma (bruise) – after surgery, formation of a hematoma in the area of the septum may occur. If this complication is present, the mucosal pocket of the septum must be opened, and then the existing blood coagulum (clotted blood) must be removed. The area is then stabilized with fibrin glue and mattress sutures. Immediate care of the hematoma is necessary, otherwise abscesses or even necrosis of the mucous membranes may occur.
- Saddle formation – after surgery has been performed, it may come during healing to the formation of a saddle nose.
Other notes
- Septoplasty can also be performed in combination with tonsillectomy (palatine tonsillectomy). This does not result in any significant difference in the frequency of unplanned re-presentations.