Chapter 30. Septal Modification
Indications: Some deflection of the nasal septum in any plane is likely present in most patients. Those with significant deviation of the septum are candidates for septoplasty since deviation of the septum limits airflow at the level of the internal nasal valve. Obstruction of 50% to 60% of the anterior and inferior aspect of the airway generally leads to symptoms of obstruction. The diagnosis is made by careful internal examination with a nasal speculum and an adequate light source. At times, the deviation may be symptomatic by impeding airflow through one or both nostrils. Preoperatively, the nature of the deviation should be identified. Deflection of the septum can be simply in one plane, such as the anterior-posterior direction or superior-inferior direction, or in a combination of planes. The patient should be questioned about prior manipulation of the septum and evidence sought on physical examination. Often a scar will be noted on one or more sides of the septal mucosa to indicate prior intervention. A cotton-tipped application can be used to gently palpate the septum if there is concern that portions were previously removed or damaged. Cartilage that has been removed and replaced as a graft usually does not retain its earlier pliability.
Markings: No external markings are necessary to plan one’s approach to the nasal septum. The extent of the septum should be appreciated so that 1 cm of dorsal and caudal cartilage is preserved as supporting elements of the remaining septum. Depending upon one’s internal approach, the proposed lateral mucosal incision may be drawn 1 cm from the caudal edge through the right nostril if the surgeon is standing on the right side of the operating room table.