CHAPTER 42 Correction of the deviated septum

History

Correction of the deviated nose remains one of the more challenging aspects of rhinoplasty surgery. Not only is the deviated nose an aesthetic concern, but it also is of functional consequence. Debate continues as to the optimal approach. Anatomic reconstruction will provide a return to normal anatomy at the risk of decreasing structural support of the osteocartilagenous framework. Camouflage techniques may provide a simpler solution to provide symmetry, however functional defects are not addressed.

Many of the pioneers of modern rhinoplasty techniques recognized the importance of the septum in the etiology and subsequent surgical approaches to the deviated nose. This understanding has become the cornerstone to the reconstruction and functional restoration of the crooked nose. However, the anatomic deviation may be at the bony pyramid, the upper lateral cartilages, the lower lateral cartilages, the caudal septum, or any combination of these entities. The ultimate goal is to provide a consistent, stable long-term correction that is both aesthetically pleasing and functionally sound.

Physical evaluation

• Thorough history: A detailed patient history including history of nasal trauma, previous nasal surgery, airway complaints, allergies, and age is obtained. A negative history of airway obstruction is not a reliable indication of a patent airway, since the patient has no basis for comparison.

• Facial analysis: The nose and face are evaluated in 3 dimensions and findings are confirmed with soft tissue cephalometric analysis of life-size photographs. This is performed in order to assess symmetry of the nose and its relationship to other facial structures. Asymmetry may be present in other facial features, thus affecting the global evaluation of the face. The AP view of the face is also used to evaluate the dorsal nasal aesthetic lines as well as the width of the nasal dorsum.

• Often, the nasal bones follow the direction of the deviated septum, however these structures may move independently. Deviation of the lower nose may involve the caudal septum, anterior nasal spine, and the lower lateral cartilages.

• Midvault deviation consistently accompanies at least anterior and commonly mid and posterior septal deviation.

• In all types of septal deviation, the middle and/or inferior turbinates may be enlarged. The enlargement is usually juxtaposed to the concave side of the septum.

• There are six classes of septal deviation.

– The most common type is a septal tilt in which the septum itself has no significant underlying curvature, but is tilted to one side (Fig. 42.1). In most cases of septal tilt, the internal deviation of the septum is to the left and the external deviation of the nose is to the right. This is usually accompanied by an enlargement of the inferior turbinate ipsilateral to the external deviation.

– C-shaped deviation of the septum may have anteroposterior or cephalocaudal septonasal orientation. Anteroposterior deviation is usually associated with deviation of the vomer plate (Fig. 42.2A). External reflexion of the anteroposterior C deviation is often similar to the septal tilt. Cephalocaudal C deviation presents externally as a C-shaped appearance of the nose (Fig. 42.2B).

– The next subtype of septal deviation is an S-shaped deformity, which may also be in an anteroposterior or cephalocaudal orientation (Fig. 42.3). Externally, the anteroposterior deviation will present with a shift of the nose to one side, whereas cephalocaudal deviation will be reflected as an S-shaped deviation of the nose.

– Finally, the last type of septal deviation is localized deviation or spur. This is a purely functional problem and has no translation to the external shape of the nose.

Fig. 42.1 Septal tilt.

Fig. 42.2 C-shaped septal deviation. A, Anteroposterior deviation. B, Cephalocaudad deviation.

Fig. 42.3 S-Shaped septal deviation. A, Anteroposterior deviation. B, Cephalocaudad deviation.

Technical steps

General anesthesia is the modality of choice for this procedure. The nose is packed with gauze soaked in 4% cocaine. If a turbinectomy is intended, the turbinate is injected using a 25-gauge needle with 0.5% lidocaine containing 1 : 200,000 epinephrine, prior to nasal packing. The nose is then injected with 0.5% lidocaine with 1 : 200,000 epinephrine, paying particular attention to the lateral and medial surfaces of the nasal bones. The columella and dorsal septum are then injected. The septum is injected as close to the floor of the nose as posterior as possible in order to provide further vasoconstriction to the septum. These injections are then repeated with lidocaine and 1 : 100,000 epinephrine after several minutes to minimize the systemic effects of epinephrine.

A stair-step incision is made in the columella and is continued on the caudal margin of the medial and lateral crura of the lower lateral cartilages bilaterally. The soft tissues overlying the lower lateral cartilages are dissected to expose the medial and lateral crura, thus giving wide exposure to the upper and lower lateral cartilages. Dissection continues along the dorsum until the nasal bones are encountered. Periosteal elevation using an Obwegeser elevator is performed to dissect in a subperiosteal plane.

Access to the upper lateral cartilages and dorsum of the nose may now be obtained by removing the soft tissue overlying the caudal septum. The mucoperiosteum is then separated from the nasal roof in order to avoid penetration of the lining. Separation of the medial crura may be performed at this point if deviation or asymmetry of the footplates exists. This will facilitate septal exposure.

Nasal bones/upper lateral cartilage

Prior to osteotomy, a push rasp is utilized in order to remove any bony hump. The rasp is angled toward the cheek to minimize the chance of septal fracture. After removing the hump, the upper nose is reassessed for symmetry. Often there may be far worse deviation than expected of the upper nose after hump removal. A medial osteotomy is first performed with a 4 or 6 mm osteotome, which is placed medial to the nasal bones and advanced cephalically with careful use of a mallet (Fig. 42.4A). A vertical osteotomy is then done with a 2 mm osteotome. The osteotome is percutaneously placed anteriorly in order to avoid the angular vessels (Fig. 42.4B). It is then directed posteriorly and cephalically and several interrupted osteotomies are made. After a small stab incision at the nasal vestibule with a #15 blade, a Joseph’s periosteal elevator is then used to incise the vestibular lining and elevate the periosteum. An internal low-to-low osteotomy is performed using a guarded osteotome and carried posterior to the natural suture line (Fig. 42.4C). A portion of the osteotomy is therefore made in the frontal process of the maxilla. This avoids the lateral step deformity seen after some osteotomies. Following adequate osteotomies, the upper lateral cartilages are assessed. There is often a discrepancy in the upper lateral cartilage length after the completion of the osteotomy. If a difference in length in the upper lateral cartilage exists, they may be trimmed in order to obtain symmetry. If the cephalic nasal asymmetry is unilateral only, the defect may be camouflaged using an onlay cartilage graft. However, correcting the unilateral defect with an osteotomy is preferred for its functional superiority.