CC
A 28-year-old male presents for a consultation regarding difficulty breathing through the left side of his nose.
HPI
The patient states he has had difficulty breathing since he was a child and always remembers his nose being deviated. The patient also reports his nose was forcefully struck in a sporting accident 4 years ago at age 24 years. (Prior nasal injury is a risk factor for deviated septum.) He reports that he underwent a closed reduction of nasal bone fractures at the time of injury; however, he was still unable to breathe well afterward. No further surgical intervention was provided at that time. Subsequent to that injury, he has not been able to breathe through his left nostril. (Nasal obstruction caused by septum deviation can occur because of birth trauma or, more likely, secondary to developmental changes or, as in the current patient, facial trauma.) He has tried over-the-counter nasal sprays (Afrin and Flonase), all without relief. He used these as directions stated and not for extended purposes.
PMHX/medications/allergies/SH/FH
The patient has no significant medical illness. The patient denies a history of abuse of cocaine or other nasally inhaled substances, such as nose drops or sprays. (Rhinitis medicamentosa can cause postoperative septal perforation caused by chronic mucosal vasoconstriction.) He does not have symptoms of nasal allergy (seasonal, caused by pollens; perennial, caused by inhaled or ingested irritants; infectious agents; or a combination of these) or vasomotor rhinitis (nasal congestion, hypersecretion, sneezing caused by parasympathetic system instability). Such conditions should be diagnosed and controlled or resolved before nasal septal surgery. It is important to discuss with the patient that these may not resolve after a septoplasty. There is no history of Wegener granulomatosis (small- and medial-sized vasculitis that can affect the nose, causing pain, epistaxis, and nasal deformities caused by septal perforation). The patient denies tobacco use. (Tobacco smoke is irritating to the nasal mucosa, and nicotine causes generalized vasoconstriction. Smoking after a nasal (or any) operation seriously interferes with the healing process and may become a critical factor in wound breakdown or the development of an infection.)
Examination
The nose is examined in conjunction with the other facial structures for both its functional and cosmetic aspects. The physical examination should include inspection and direct visualization of the septum, turbinates (inferior, middle, superior), nasal mucosa, nasal passages, nasal valve (internal and external), radix, dorsum, columella, and anterior nasal spine. (Occasionally, a tumor occurs in the nasal passages, and an area showing changes suspicious for neoplasia should be biopsied.) The examination of the current patient proceeded as follows.
External nasal examination
The nasal bones are stable and symmetric. The tip and columella are deviated to the left. The anterior nasal spine is palpated and appears coincident with the facial midline, but the cartilaginous caudal septum is deviated to the left. The bony radix and dorsum are in the midline. The external cartilaginous caudal nasal structures (dorsum, tip, columella) show only mild deviation to the left. (Significant septal deviation is not always associated with a cosmetic nasal deformity of the columella, dorsum, or tip.)
Rhinoscopy
Rhinoscopy is examination of the nose with a speculum. The nasal mucosa is nonerythematous with normal moisture and absence of polypoid tissue. (Erythema, excessive secretions, and polyps would be indicative of allergic rhinitis.) The quadrangular cartilage and bony septum are significantly deviated to the left, closing the nasal valve angle with nearly complete blockage of the airway, prominent midseptal bowing, and contact of the septum with the left inferior turbinate. The septum is also deviated inferiorly to the left. Bilateral inferior turbinates are enlarged, with the right larger (compensatory turbinate hypertrophy) than the left. The left nasal valve is obstructed by this deviation.
Endoscopic nasal examination
After spraying the nose with oxymetazoline (α 1 agonist and partial α 2 agonist), endoscopic examination confirms the presence of right inferior turbinate hypertrophy and leftward deviation of the septum with no visible mucosal pathology. (Endoscopy is not necessary to diagnose and treat a deviated septum. However, it can be helpful in the evaluation of the posterior nasal structures, i.e., the superior nasal passages, the paranasal sinus meatuses, and the posterior nasal choanae, especially in the absence of computed tomography [CT] examination.)
Cottle’s test
The test result was negative and did not improve airflow in the current patient. The test is done to evaluate airflow caused by nasal valve obstruction or compromise. The contralateral nostril is gently closed by the examiner, and the ipsilateral cheek is pulled laterally to open the nasal valve. If airflow is improved by this maneuver, the internal nasal valve deficiency is potentially contributing to airflow obstruction. (This is an unreliable test that produces many false-positive results; that is, lateral retraction of the cheek improves the airway in many patients who only have temporary nasal mucosal ingestion, not collapse of the nasal valve. Therefore, the examiner should be wary of the validity of this test with regard to nasal valve integrity.)
Imaging
Advanced imaging studies (CT) are not necessary to diagnose a deviated septum. However, CT or in-office cone-beam computed tomography (CBCT) are helpful in the evaluation of the location and extent of the deviation and in the assessment of the turbinates, paranasal sinuses, and other related structures for additional pathology. Imaging like this also helps visualize the bony septum discrepancies. The panoramic radiograph is not used for definitive evaluation of the nasal septum. However, this routinely obtained plain film does afford basic two-dimensional anteroposterior visualization of the septal position and can be used as a screening tool.
In the current patient, axial and coronal CBCT imaging demonstrated significant leftward deviation of the septum with reduced air space and compensatory enlargement of the right inferior turbinate ( Fig. 86.1 A and B). The panoramic radiograph obtained for third molar evaluation in this patient shows impaction of the mandibular third molars and demonstrates the deviated septum ( Fig. 86.1 C).
Labs
No routine laboratory tests are indicated for nasal septoplasty surgery in an otherwise healthy patient. However, patients with a family history of clotting disorders are screened for possible undiagnosed coagulopathies (e.g., von Willebrand disease, platelet deficits or dysfunction, liver pathology, and clotting factor deficiencies). Patients taking anticoagulant medications are at risk for hematoma formation and uncontrolled hemorrhage.
Assessment
A 28-year-old male with severely deviated nasal septum to the left, involving the quadrangular cartilage and the bony septum, causing impaired left nostril airflow and compromised flow in the right because of compensatory inferior turbinate hypertrophy.
Treatment
In the current patient, general anesthesia was induced, and an oral endotracheal tube was placed for airway maintenance and administration of oxygen and anesthetic agents.
Two main incisions are used to approach the septum: the Killian incision and the hemitransfixion incision ( Fig. 86.2 ). The Killian incision is the most common and is used to approach the septum without direct access to the caudal segment. It is the best incision for preserving tip support. The hemitransfixion incision allows exposure of the caudal septum and anterior nasal spine by placing the incision in the membranous septum just anterior to the cartilage. Critics of this incision argue that it can weaken tip support by affecting the foot plates of the lower lateral cartilage. The septum can also be approached via the open rhinoplasty incision (transcolumellar). This is usually done when nasal and septal surgery for both cosmetic and functional correction are planned. Access to the septum via the Le Fort I osteotomy is easily done in combination with orthognathic surgery. Correction of the deviated septum should be included in the orthognathic surgical plan. Special consideration is required with maxillary impaction because the vertical height of the septum must be reduced adequately to allow the planned amount of maxillary superior intrusion and to avoid compression and postoperative nasal septum deviation.
