Deviated nasal septum is one of the commonest clinical conditions encountered in the day to day otolaryngological practice. Surgical correction of this condition has undergone numerous modifications over the centuries, owning to various drawbacks of the classical submucous resection of septum, which was initially described in the nineteenth century. The pitfalls of various procedures are discussed at length. We put forward a few modifications of the surgical technique, considering the merits and demerits of the radical submucous resection of septum as well as conservative septoplasty surgery. We further propose a new nomenclature "Modified Septoplasty" to incorporate the modifications.
Septoplasty, Septal incisions, Columellar retraction, Septal perforation, Supratip deformity.
Deviated nasal septum (DNS) is a clinical entity which can give rise to a number of complications and can jeoparadise the quality of one's life if not treated judiciously. A patient with a DNS can suffer from nasal obstruction, mouth breathing, recurrent and persistent epistaxis requiring hospital admission, chronic sinus problems, headache, recurrent sore throats, middle ear effusions and even voice problems. Significant septal deviations require surgical correction to prevent these serious complications. Anatomically the nasal valve area gives rise to maximal nasal obstruction in DNS.
Nasal Valve :
The upper lateral cartilage is overlapped by the cephalic edge of the alar cartilage, to which it is attached by dense connective tissue. This creates a ridge across the roof of the nasal vestibule which forms the inner nasal valve (Fig 1). This is the narrowest part of the nasal cavity. Clinically this obstruction to nasal airflow can be confirmed by the Cottle's test. Septal deviation in the region of nasal valve area causes the greatest obstruction.
Fig 1: Nasal Valve Area
Review of Literature :
Over the centuries numerous surgeries have been proposed for the correction of DNS. Sub mucosal resection, more commonly known as the SMR operation, is the time tested and established surgical procedure for treating a patient with DNS. SMR was probably first done by Ingall in 1881. But Killian and Freer did the refinement and popularized the actual procedure of Ingall (1882). It was Killian (1904)who described the technique where a dorsal and caudal strut of septal cartilage is retained and most of the cartilaginous and bony septum is removed. Freer (1902) opined that the septal cartilage did not contribute to the support of the nasal pyramid and could be completely removed if required by the extent of the pathology. SMR operation had quite a few complications on record like saddling of the nose (supratip deformity), collumellar retraction, septal perforation, epistaxis etc.
Killians admitted that "saddling" of the dorsum did sometimes occur in the supratip region, but concluded that this was always due to rough surgery, which damaged or partly removed the upper lateral cartilages. The supratip saddling and columellar retraction are the complications which were documented too frequently in Killian's technique. Immediate saddling is rare but it usually occurs as a result of scar contraction in the septum. Some surgeons have attempted to solve the problem of scar contraction by replacing all or part of the excised cartilage. Other authors have avoided producing a large defect in the cartilaginous septum by mobilizing and repositioning the septum in the central position, so that the bulk of the cartilage is retained and is still attached to it mucoperichondrium as part of a compound flap: Metzenbaum's "Swinging door" technique (1929). Recurrence of deflection was common in this technique. Peer in 1937, completely excised with a deviated caudal segment to overcome the problem with the technique of Metzenbaum. He advocated reinsertion of the cartilage as a free graft. This operation developed the concept of cartilage excision followed by cartilage replacement. Galloway (1946) removed the entire nasal cartilage and replaced the anterior septum with a single free autograft fashioned from the excised cartilage. It was always successful. The whole process of septal removal followed by septal replacement has some inherent drawbacks and consequently the alternative solution of mobilisation and repositioning of septal cartilage has been revived and further developed.
This concept received a new nomenclature"Septoplasty" and has been popularized by Cottle and his associates. Rubin (1983) advocated the morselization of the deviated septal cartilage by crushing with a morselizer after the mucosal flaps have been elevated on both sides. It isclaimed that the new flattened shape of the cartilage is retained on a permanent basis.
The different incisions advocated for the septal surgeries are as follows:
Hajek / Freer's Incision (Fig. 2) : Fashioned at the extreme anterior margin of the septal cartilage if the deviation extends into the vestibule of the nose. It may result in columellar retraction, if not properly taken.
To prevent columellar retraction the Freer's incision is to be made as high as possible because a low incision through the membranous septum may be followed by a retraction of the columella. It is therefore necessary to displace the columella downwards and to the opposite side by means of traction exerted with dissecting forceps or a Cottle's columellar clamp. The lower border of the septal cartilage will then be plainly visible and the incision made down to the perichondrium, which is incised and the subperichondrial flap elevation then commenced. This is known as the "Maxilla-premaxilla" approach of Cottle.
Killian's Incision (Fig. 3):
Fashioned at the junction of the vestibular membrane with the mucous membrane of the septum.
According to Ballenger, Killian's incision is preferable for septal surgery and it should be made upon the left side of the septum. In reality it has been seen that in Septoplasty cases if the patient has a caudal deviation or a deviation at the anterior part and the valve area is encroached by the deviated cartilage, Killians incision is not satisfactory. As this incision is fashioned over the mucocutaneous junction a residual deviation is maintained at the anterior septal end which abuts over the nasal valve area and the nasal obstruction is maintained.
Fig-2: Freer's / Cottle's Incision
Therefore the preferred incision in Cottle's septoplasty is as advocated by Freer. This incision is made at the lower border of the septal cartilage. A unilateral (hemitransfixation) incision is adequate for a septoplasty and for a right handed surgeon this is usually made on the left side.
Fig-3: Killian's Incision
Advocated Modifications :
1. The incision should be taken 1 to 2 mm posterior to caudal end of quadrilateral cartilage, as classical Freer's/Cottle's incision may give rise to columellar retraction.
2. After elevation of the mucoperichondrial flaps on both sides like SMR operation, the deviated quadrilateral cartilage and the perpendicular plate of ethmoid are cut close to their attachment with upper lateral cartilage and crest of the nasal bones respectively by the Ballenger's scissors or any such types of scissors. Thereafter, the deviated cartilage and bone of the septum are removed. This would prevent supratip deformity.
3. To prevent flap damage which results in septal perforation, the anterior and inferior tunnel should be created routinely, as advocated by Cottle.
These recommendations if followed meticulously in septoplasty, the complications like columellar retraction, supratip deformity and septal perforation which commonly give rise to facial deformity, can be avoided. Hence we strongly suggest that a new nomenclature "Modified Septoplasty" should be acknowledged.
We are grateful to the Secretary, Swami Satyadevananda Maharaj, Vivekananda Institute of Medical Sciences for allowing us to publish the article. We are thankful to Dr. Abhishek Gupta, DNB PGT, for helping us in preparing the article. We are also thankful to all the doctors in the department for their assistance.