While precision technique and experience are critical to a successful surgical outcome, strategic preoperative planning is the most important step in the care of these patients. The nasal surgeon should not prescribe to any one septoplasty “style.” The vast array of different septal pathology demands an armamentarium of surgical approaches and techniques to manage the individual patient. While a classic submucous resection is certainly no longer necessary for every patient, at the same time, an overly conservative septoplasty can leave inadequate results. The first step after performing your evaluation is to decide if the patient can be approached using an endonasal vs. open septorhinoplasty technique. Conditions that may necessitate an open approach include severe dorsal septal twisting or deviations contributing to airway obstruction, nasal tip ptosis, severe caudal septal deflections, and deficient nasal valve architecture requiring open cartilage grafting. Standard incisions involve either a hemitransfixion or Killian’s incision and should be adapted to the individual patient (Fig. 31.3) [10].

Surgery can be performed using either general anesthesia or local techniques with/without sedation. After anesthesia induction, a throat pack is typically placed to prevent the collection of blood in the hypopharynx and stomach. However, there is no evidence that this reduces postoperative nausea and vomiting. Recent work suggests it may be more efficacious to remove blood using an orogastric tube at the end of surgery [33]. The septum is prepped in the same fashion regardless of whether the patient receives general anesthesia. The two main purposes of a septal injection are hydrodissection and vasoconstriction. This is critical and the first technique taught to anyone learning the art of septal surgery. A topical solution of oxymetazoline (0.05 %) is placed in the nasal cavity bilaterally using nasal pledgets or cotton balls. Next, 1 % lidocaine with 1:100,000 solution is injected using a 25-gauge needle or smaller along the septum in a subperiosteal and subperichondrial plane. A stepwise injection technique is used where the edge of the dissection bleb from the prior injection is used as a starting point to develop the next area of hydrodissection. The oxymetazoline pledgets are then replaced while scrubbing and prepping the patient to allow time for adequate effect. Higgins et al. [34] completed a systematic review of topical vasoconstrictors used in nasal surgery. They emphasized safe and judicious use of these medications and recommended avoiding topical phenylephrine if possible along with cautious use of topical cocaine [34]. Beta-blockers should be avoided to treat hypertension during cases using alpha adrenergic agonists to avoid unintended development of pulmonary edema [35, 36].

The efficacy of hydrostatic injections is controversial. Studies do demonstrate that the perichondrial layer provides the largest amount of tensile strength and thus a subperichondrial dissection is logical and favored [37]. However, the technique of hydrodissection has been questioned. A cadaveric study by Dubach et al. [38] demonstrated only 25 % (5/20) of experimental cases with injections performed in the correct dissection plane. Most injections were either in the perichondrium itself or supra-perichondrial [38]. This may be an area for further investigation and research.

The traditional submucous resection of the septum dates back over half a century with the instrumentation and surgical technique mostly unaltered over time. After appropriate surgical preparation, the procedure begins with one of the traditional incisions (Fig. 31.3). Typically, for a classical submucous resection, a Killian’s incision is made on the left side of the septum. This approach is generally taken due to the predominance of right-handed surgeons. However, a right-sided incision can be made as well if deemed necessary for the particular clinical circumstance. A no. 15 blade knife is used to incise through the mucosa and perichondrium. This is a key part of the procedure, and much time will be saved later in the procedure if some additional patience and attention are paid to this step. If the dissection starts in the incorrect surgical plane, the operation will inevitably be more difficult with an increased likelihood of mucosal tears and loss of subsequent flap integrity. The proper plane of dissection is determined by visualization and tactile feedback with the instrumentation. With modern-day halogen headlights used in the operating room, the septal cartilage will reflect back almost a slight bluish hue that is bright white in color. With proper vasoconstriction, the subperichondrial plane should be avascular with minimal bleeding. Excessive bleeding from inside the flap indicates that the dissection may be progressing at the incorrect depth. It is even acceptable to begin dissecting just slightly into the superficial layer of the cartilage itself to ensure that one is deep enough within the plane of dissection and then back off into the proper layer. In an atraumatic patient with no prior nasal surgery, the subperichondrial plane will dissect quite easily also providing an indicator of a correct surgical dissection level. After incising with the scalpel, a sharp elevator is used such as a Cottle elevator or Tebbetts™ septal elevator. Carefully, the flap is elevated using this instrumentation until an adequate length of flap is raised to allow for the introduction of a nasal speculum in a vertical orientation. At this point, one can use a less aggressive instrument such as a Freer elevator if preferred or continue with a sharp elevator if needed to continue flap dissection. The dissection is carried posterior to the bony-cartilaginous junction. There is usually a small area of flap adhesion at this line that requires some careful elevation. Once dissection proceeds to the bone, the surgeon needs to reconfirm if he or she is working in the correct plane. At any point in the dissection, when transitioning between different bones or from cartilage to bone, there is usually a small amount of flap adhesion at these suture lines. As the surgery proceeds along the perpendicular plate of the ethmoid bone, care is taken to avoid dissection near the cribriform plate but high enough so that all areas of structural deviation are addressed. The flap is elevated down to the floor of the nose. The septal flaps may fold over and sit deeply in the groove between the quadrangular cartilage and maxillary crest. Therefore, this area of flap elevation should typically be done last. A Pierce elevator may be useful in this circumstance especially with more inferiorly located spurs. Next, a transcartilaginous incision is created along the caudal septal cartilage. Care is taken to leave at least a 1-cm caudal strut. This can be performed using a scalpel knife or sharp elevator. Typically, an elevator is adequate and less likely to create a contralateral perforation in the mucosa. A contralateral flap is raised on the opposite side similar in fashion to the initial dissection. A long nasal speculum is then inserted fully back to the face of the sphenoid rostrum once the flaps have been fully developed. At this point, a swivel knife can be used to remove a large section of deviated cartilage and set aside for later replacement if necessary. Deviated portions of the perpendicular ethmoid plate and vomer are removed using Jansen-Middleton cutting forceps. Care is taken not to use any torsional force when removing these superior portions of the bone to avoid a CSF leak. Once the superior attachments are free, the lower sections of the bone and spurs can be removed more aggressively using a grasping instrument such as Takahashi forceps. Large 90° oriented spurs that prevented adequate flap elevation earlier in the procedure can now be fractured off the floor of the nose using an elevator and gently teased away from the attached mucosa. Anterior, there is typically a strip of cartilage still in place along the maxillary crest that can be removed using a Freer elevator. Small deviations in the maxillary crest are typically not responsible for symptomatic nasal airway obstruction as opposed to high septal deviations along the nasal valve region. Aggressive removal of the maxillary crest can lead to subsequent postoperative dental anesthesia. Therefore, discretion must be used in judging whether to remove portions of this bone. If necessary, a 4-mm chisel and mallet can be utilized to remove any deviated sections. Care should be taken throughout the procedure to preserve a 1-cm caudal and dorsal strut for structural support and prevention of postoperative nasal tip ptosis and/or dorsal saddle nose deformities. Upon completion of the resection, the amputated cartilage graft can be reformed and flattened using a press and replaced between the flaps. This is generally more important in scenarios where a bilateral opposing septal mucosal tear exists after flap elevation. Care must be taken upon closure to not allow the cartilage graft to “slip” inferior and sit alongside the remaining maxillary crest creating a new postoperative septal deformity. The incision can be closed using absorbable suture such as 4–0 chromic gut. Especially if a cartilage graft was replaced, quilting sutures are recommended using absorbable suture such as 4–0 plain gut with a straight needle to avoid mucosal trauma. Running quilting sutures should be used with caution which can cause strangulation of the septal mucosa if done in a circumferential fashion. Sutures placed in an interrupted fashion can avoid this potential problem. If a mucosal tear does not already exist from the prior dissection, a drainage incision needs to be created posterior-inferior to prevent postoperative hematoma formation. Use a scalpel blade to create a puncture site in conjunction with angled scissors.

Evolution from the days of Gleason and Watson to the contemporary septoplasty has been slow and stepwise. The modern-day septoplasty emphasizes structural support and tissue conservation. A hemitransfixion incision is typically utilized to open the caudal septum, but some variation starting more posterior is also appropriate depending on the location of the pathology. Again, emphasizing that every septum is unique, thus the surgery should be tailored and adapted to the individual patient. A subperichondrial flap is raised again on the left side typically as with the submucous resection. However, instead of removing the quadrangular cartilage, the bony-cartilaginous junction is identified and divided using the Freer elevator with contralateral flap elevation. At this point, deviated sections of bone are removed using cutting forceps. Since the cartilage is still in place, this dissection takes place in a smaller space. Care must be taken not to perforate the posterior superior flap and injure the middle turbinate. Surgical treatment of the anterior cartilage is an expansive topic with volumes of text written on individual subunits such as the caudal septum. Techniques emphasize different variations of conservative cartilage removal with repositioning of the remaining structural elements. Commonly, an inferior thin strip of cartilage is removed allowing the cartilage to realign into proper position classically known as the “swinging door” technique. Remaining memory might require further scoring using a sharp instrument such as a Freer knife. Curvature can still remain in a severely deviated septum, and many times, it is also prudent to raise a contralateral flap anterior through the hemitransfixion incision fully isolating the anterior cartilage and removing any attachments of the opposing mucosa. Despite cartilage scoring techniques, the contralateral mucosa can remain a barrier to allowing the cartilage to relax into a neutral position. Further suturing may be required to hold the septum in position along the maxillary crest. A caudal septal deviation can be a challenging and vexing problem. If treated through an endonasal septoplasty approach rather than an open rhinoplasty, full bilateral flap elevation is typically necessary. The question at this point is whether to remove the cartilage and replace it with a reformed cartilage graft or try to realign the cartilage in situ. If cartilage segments are removed from the caudal septum, it can be difficult to replace these grafts in an endonasal fashion. Some authors have advocated the use of polydioxanone (PDS) foil (Ethicon Inc, Johnson & Johnson) as an adjunct to septal reconstruction [39–42]. Sections of resected cartilage are laid out on a piece of PDS foil and sutured in place. A second piece of foil can be placed on the opposite side for further support. The graft is then sutured in place between the septal flaps. The incisions are closed in a standard fashion as with a traditional submucous resection.

Endoscopic septoplasty is a newer technique that has come about with the advent of endoscopic sinus surgery. The ideal candidate for a minimally invasive pure endoscopic septoplasty is the patient with an isolated posterior bony spur or anatomic deformity. The area is injected directly with local anesthetic solution to hydrodissect the mucosa off the bone. This is done under direct endoscopic guidance using either a long 25-gauge spinal needle or tonsil needle. A small limited mucosal flap is raised off the spur exposing the bone. The spur can be directly removed using a small diamond burr. Otherwise the section of deformed bone can be fully cut out and isolated with dissection off the contralateral flap. The small mucosal flap is just laid down without any suturing. If done in conjunction with sinus surgery, the middle turbinate can many times be sutured in place against this area for support. A “blended” or “back-and-forth” technique is now becoming more common [43]. A variation of endoscopic septoplasty, the septal incisions are made through a traditional approach, but the endoscope is used between the flaps intermittently throughout the procedure to provide magnified visualization of the posterior structures and assistance in raising flaps in challenging areas.

Aggressive partial or complete inferior turbinate resection including the overlying mucosa can lead to long-term complications of atrophic rhinitis or “empty nose syndrome.” This procedure is not advocated by the authors and will not be detailed for that reason. A traditional submucous resection involves first injecting the turbinate in a submucosal fashion along its length on each side using a standard local anesthetic solution used in septal surgery. An incision is made along the anterior two-thirds of the turbinate and a mucosal flap raised along the bone. Cutting instruments such as a Jansen-Middleton forceps or long scissors are used to remove a section of the bone. The flaps are then laid back in position and not typically sutured in place. The turbinates can be outfractured to provide additional expansion of the airway.

Microdebrider-assisted turbinate reduction is widely used today to address inferior turbinate pathology. The technology is readily available during endoscopic sinus surgery cases further lending to its convenience and surgeon comfort with the device. The anterior turbinate head and body are again injected with local anesthetic solution, allowing time to have its effect. Under direct endoscopic visualization, the tip of the blade can be used to make a puncture incision along the anterior head of the turbinate and subsequently raise a small submucosal pocket as far posterior as necessary to address the degree of turbinate hypertrophy. Alternatively, a no. 15 blade knife can be used to make a small anterior incision with a standard Freer elevator then utilized to raise the flap. As the flap is raised, care must be taken not to tear a lengthwise flap or create posterior perforation sites. Various microdebrider blades exist from different manufacturers with some designed specifically for inferior turbinate use. In general, the blade is passed into the pocket with the cutting edge of the blade facing lateral. Debridement is performed posterior to anterior but can move back and forth if necessary. Attention should be paid anterior-superior to the area of the internal nasal valve. The blade needs to be angled superior to reach this area when moving anterior, which can be a critical area of obstruction. The turbinates are then outfractured if deemed necessary.

Radio-frequency ablation can be done alone as an office-based procedure or in the same setting as other concurrent nasal surgery. Again, settings for the equipment vary based on the manufacturer. The general principle involves making multiple passes using a needle electrode tip device in a submucosal plane along the length of the turbinate. Energy is delivered through the tip to the surrounding tissue. Care must be taken not to burn the edge of the nasal vestibule when using these devices.