Contemporary Septoplasty Techniques

日鼻誌 58（1）：1～ 7，2019 Review Contemporary Septoplasty Techniques Jong Ik Lee, Yong Ju Jang Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea （Received: January 18, 2019, Accepted: February 7, 2019） paper classifies this condition into 5 types and have found Introduction this system to be very practical8). These are: The most common cause of a nasal obstruction is a devia- 1. Focal projection or deviation due to a bony spur or ridge tion of nasal septum1). This condition can also affect nose (Fig. 1). This type is characterized by the presence of a functions such as humidification, olfaction, air filtering and bony spur or ridge in the vomer or maxillary crest only temperature regulation and thereby has significant quality of and not accompanied by a cartilaginous deviation. Focal life impacts2). If conservative medical management is unsuc- resection of protruding bony portions may be sufficient cessful in relieving the symptoms of a nasal obstruction, to correct this type of deformity. surgical intervention to correct the septal deformity is indicated3). 2. Deviation of mid or posterior septum (Fig. 2). Correction The rigid framework supporting the nasal airway is provided is relatively easy and can be achieved by removal of the by the bony and cartilaginous septum and paired nasal bones. deviated bone and cartilage whilst leaving a sufficient The bony septum consists of the vomer, perpendicular plate L-strut. of the ethmoid bone, and maxillary crest4). Nasal septal 3. Caudal septal deviation (Fig. 3). Because the caudal devia tions vary greatly in shape and location among patients. Thus, successful correction of the deviated septum cannot be achieved using the same surgical approach in all affected individuals. Different surgical techniques such as submucosal resection, conventional septoplasty, and endoscopic septoplasty has thus been described to treat this condition5). When one consider the anatomical subsite of the nasal septal deviation, correction of the caudal septal deviation is one of the most important and challenging area for a correction using septoplasty. In this present review, we aimed to highlight some of the recent developments in septal surgery with a particular emphasis on caudal septal management. Classifications of Septal Deviation Although many different classification systems have been suggested for a septal deviation, including those Fig. 1 Focal projection of a bony spur to the right side of the descried by Guyuron6) and Mladina7), the senior author of this nasal cavity ―1― 日鼻誌 58（1），2019 Fig. 2 Septal deviation of the mid-part due to a bony deviation to Fig. 4 High septal deviation to the right side the right side preservation of a sufficient L-strut is the best approach to correct this. 5. Mixed deviation: In reality, it is difficult in most cases to make a clear distinction between the four types of devia- tions described above. A mixed type of deviation is most commonly encountered in clinical practice8). Surgical Treatment of a Caudal Septal Deviation 1. Caudal septal batten grafting using septal cartilage A hemitransfixion incision is made at concave side of caudal septum, at the end of the caudal septal cartilage. Submucoperichondrial flap is found and elevated using an Iris scissors and Freer elevator. Elevation of the flap continues in the cephalic and anterior directions. The deviated portion of the septal cartilage and bone is then harvested by excision. A Fig. 3 Caudal septal deviation to the left side sufficient L-strut should remain for septal support. If there is still caudal septal deviation, a contralateral septum is important for nasal support, resection of deviated flap is elevated via a hemitransfixion incision site without caudal part as a correction approach is practically im- making an additional incision on the opposite side. After possible. This type of deviation is therefore the most bilateral flap elevation, a subperichondrial dissection into the difficult to correct. Additional surgical techniques other nasal floor is performed to form a pocket in which a graft can than simple resection of deviated portion are thus often be inserted. Harvested septal cartilage is usually used for a required to modity this problematic deviation. batten graft, which has a counter-curvature location on the 4. High septal deviation (Fig. 4). The most common cause concave side and is stitched using a few 5-0 polydioxanone of high septal deviation is a secondary change from the sutures. The gap between the posterior portion of the batten deviated perpendicular plate of the ethmoid bone. Resection graft and the caudal septum is approximated through-and of the deviated bone and bordered septal cartilage with through transcartilage sutures (Fig. 5)9). ―2― 日鼻誌 58（1），2019 3. Cutting and suturing technique for the caudal septum Elevation of the bilateral septal mucoperichondrial flaps and resection of the deviated the septal cartilage and bone are done as described above. When the caudal septum is severely deviated, the caudal strut is cut using straight scissors at the most convex area in the caudocephalic direction. The excess portions of the upper and lower caudal strut are overlapped slightly, and the overlapping cartilages are fixed together using 3 to 4 stitches (5-0 polydioxanone sutures). Straightening Fig. 5 Septal batten graft is placed on the concave side of the caudal septum of the caudal septum can be evaluated immediately after this technique. The degree of overlapping cartilage is adjusted individually so that the original vertical distance is not short- 2. Caudal septal batten grafting using septal bone ened. If the stability of the newly created caudal septum is of A hemitransfixion incision and removal of deviated concern, cartilaginous or bony batten grafting is done from septal cartilage and bone, and an elevation of the conralateral the harvested autologous septum to reinforce the septal mucoperichondrial flap are achieved in the same manner as support, also usually on the concave side. After closure of the cartilaginous batten grafting technique. The amount of the hemitransfixion incision, 2 or 3 through-and- through harvestable septal bone should be sufficient to cover the full transmucosal sutures (4-0 polydioxanone) are used to hold both length of the caudal septum. After this, subperichondrial flap mucosa tightly to the newly created caudal septum (Fig. 6)11). is extended to subperiosteal elevation of the nasal floor to generate a sufficient space to insert bony graft. The harvested 4. Caudal septal division and interposition batten grafting septal bone is customized to the width and length of the Elevation of the bilateral septal mucoperichondrial flap remnant caudal septum and multiple small holes are drilled and resection of the deviated septal cartilage and bone are done to enable easy suturing. The caudal septal batten graft is with the same technique described above. The remaining positioned in the desired location, usually on the concave side caudal L-strut is cut at the most convex portion. A batten and fixed with 5-0 polydioxanone sutures. To minimize the graft with harvested septal cartilage or bone is then inter- gap between the bony batten graft and the caudal septum, posed between the cut ends of the caudal L-strut, mobilizing 1 or 2 through-and-through transcartilage and transbony (5-0 the upper part of the caudal septum toward the concave side polydioxanone) sutures and 2 or 3 through-and-through trans- of the nasal cavity. The newly created caudal septum with mucosal (4-0 chromic gut) sutures are applied to the newly the upper and lower parts of the caudal septal cartilage and created caudal septum10). interposed batten graft are adjusted to reproduce the original vertical distance of the caudal septum. The realigned caudal Fig. 6 Cutting and suturing technique for the caudal septum. (A) An incision is made at the convex-most part. (B) Cut-ends of the septal cartilage are overlapped and sutured. (C) A batten graft can be placed at the concave side to provide additional support. ―3― 日鼻誌 58（1），2019 Fig. 7 Illustration of the surgical procedure. (A) Cutting of a caudal L-strut at the most-bent portion. (B) Interposition of a batten graft between the cut ends of 2 septal cartilage flaps and fixation with PDS sutures. L-strut and batten graft are then fixed with 5-0 polydioxanone can also be a cause of postoperative obstruction. If there sutures until sufficient stability is obtained. If the strength is persistent nasal obstruction with a straight septum, of the caudal septum is insufficient, additional batten grafting other causes may be considered such as allergic rhinitis is done at the original concave side to obtain more support or paranasal sinusitis. In our experience, insufficient (Fig. 7). correction of the caudal septum is the most common cause of persistent nasal obstruction, due to the supposed 5. Modified expracorporeal septoplasty (ECS) difficulty in correcting a caudal deviation with conven- A deviated nasal septum that is difficult to correct with tional septoplasty8). the endonasal approach, due to a severe septal deviation that 2. Septal hematoma. This refers to the collection of blood will likely prevent preservation of the L-strut, is the major under the mucoperichondrium or mucoperiosteum of indication for an ECS. In this procedure, the osseocartilaginous the nasal septal cartilage or bone. An iatrogenic septal septum is exposed using an open rhinoplasty approach. The hematoma can arise as a complication of nasal surgeries. septum is then freed from the extrinsic forces of the deformed If the patient feels a persistent nasal obstruction, pain, upper and lower lateral cartilages. The septal cartilage is or tenderness, the surgeon must perform an immediate removed except for the remaining few millimeters of keystone exam of the nasal cavity.

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