Correction of deviated nasal septum

Children below 2 years
Closed reduction (septal repositioning) with Walsham’s neonatal septal forceps, ideally within 3 weeks of birth. Blades of the forceps introduced along floor of nasal cavity & downward pressure applied with it on hard palate for 30 seconds. During this period, nasal septum is manipulated into midline.

Children between 2-4 years
Closed reduction with regular expansion of a mould inserted between alveolar margins of upper jaw. This depresses the hard palate & results in automatic reduction of septal deformity.

Children above 4 years
Conservative Septoplasty. Excised segments are reinserted & nasal packing done for at least 4 days.

Adults
Conventional septoplasty

PROCEDURE OF CONVENTIONAL SEPTOPLASTY

• Pre-medication given 30-45 minutes before operation. Nose packed with 10 ml, 4 % Lignocaine mixed with 1 ml, 1:1000 adrenaline for 30–45 minutes. Antiseptic dressing (with Betadine & spirit) & draping done.

• 2 % lignocaine with 1:2 lakh adrenaline infiltrated using 26 gauge, 1.5-inch needle on both sides of septum, incision line, maxillary crest & over spurs, with bevel of curved needle facing septum. Infiltration done from above downward and from behind forward. Wait for 15 minutes.

• Freer’s gently curved vertical incision made on concave side along the caudal border of quadrangular cartilage. Incision made on convex side in case of large spur or caudal dislocation of septum.

• Cottle’s 5-tunnel technique: Septal columellar hemitransfixion incision made. Mucoperichondrial flap elevated from septal cartilage (below upward) to raise the ipsilateral anterior tunnel. Mucoperiosteal flaps elevated on both sides of maxillary crest to raise the contralateral + ipsilateral inferior tunnels. Ipsilateral anterior tunnel joined with ipsilateral inferior tunnel by sharp dissection across chondrovomerine junction. Septal cartilage dislocated from maxillary crest inferiorly & vomer + perpendicular ethmoid plate posteriorly still attached to its mucoperichondrium on contralateral side. Mucoperiosteal flaps elevated on both sides of vomer + perpendicular ethmoid plate to raise the contralateral + ipsilateral posterior tunnels.

• Submucoperichondrial and submucoperiosteal flaps elevated with Freer’s elevator, with its concave side facing the ipsilateral surface of septum. Direction should be upward & backward & stay above chondrovomerine junction. Knife used in post-traumatic fibrosis. Submucoperichondrial flaps elevated on both sides in case of gross bowing to avoid post-operative recurrence of corrected deformity due to traction of unelevated mucoperichondrium. Osteocartilaginous junction (between quadrangular cartilage and vomer + ethmoid plate) dislocated with tip of Freer’s elevator. Direction of Freer’s elevator changed so that its concave side faces the opposite surface of septum and the opposite submucoperiosteal flap elevated.

• Septal bone removed in stepwise increments with sharp Luc’s forceps or Rounger. Avoid twisting of perpendicular plate of ethmoid. Strong bone-cartilaginous attachment maintained superiorly (key stone area) between quadrangular cartilage and ethmoid plate to prevent post-operative saddling of nose. Ideally the bony septum should be fractured & brought in midline & not resected, as it does not go back into its original shape like the cartilage.

• Grossly twisted or deformed cartilage resected with preservation of caudal and dorsal strut of at least 1.5 cm width. Caudal strut prevents columellar retraction & dorsal strut prevents post-operative saddling of nose.

• Increased vertical length of cartilage corrected by removing 4 mm inferior strip of cartilage & / or gouging maxillary crest after creating inferior tunnel on either side. For gouging of maxillary crest, the gouge is placed just posterior to anterior nasal spine. Bleeding from the incisive arteries during gouging controlled by gouging the bone on the mouth of the bleeder or plugging the opening with bone wax. Deflected anterior nasal spine should be fractured and realigned into the midline.

• Mild bowing of cartilage corrected by scoring or partial thickness cross-hatching on concave side. Gross bowing of cartilage corrected by full thickness (sparing opposite mucoperichondrium) checkerboard cross-hatching on concave side or wedge excision or shaving of cartilage on convex side. Morselization of cartilage can also be done.

• For caudal dislocation, elevate mucoperichondrium, free the cartilage from maxillary crest & do vertical-strip excision of the fracture line on convex side. Next make a pocket in columella with fine scissors and put the mobilized caudal end into the pocket. Anchor the caudal strut to periosteum of anterior nasal spine periosteum with Wright’s figure of 8 suture, which goes through cartilage & anterior nasal spine periosteum only once. Knot tied on the concave side of cartilage. Another method is the Metzenbaum’s swinging door technique. Mucoperichondrium elevated on the convex side (opposite to the caudal dislocation). Fracture line on convex side excised to create a caudal swinging door segment still attached to the opposite mucoperichondrium. This segment is repositioned in midline by anchoring it to periosteum of anterior nasal spine periosteum with Wright’s figure of 8 suture.

• Cartilaginous spurs excised with knife & bony spurs gouged tangentially. At the end of surgery, septum should be in center without any external force.

• Reasons for septum not coming in midline:
1. Septal cartilage still overlaps the bony septum. Trim further.
2. Enlarged inferior or middle turbinate. It is outfractured with Freer’s elevator or partially resected.
3. External nasal deformity. Free dorsal skin and subcutaneous tissue from cartilaginous nasal skeleton with Knapp scissors introduced through an intra-nasal inter-cartilaginous incision. Upper lateral cartilage released from nasal septum.

• Close incision & tears with 4-0 catgut. Pack nose lightly with Vaseline glove pack for 24-72 hours according to severity of bleeding. Suture both packs together in front of columella over gauze piece. Nasal splint (wax plate or silastic plate) inserted only if opposite surfaces are raw and removed after 7 days. Dynaplast bandage put to keep the packs in position.

• Old theory of packing: Pack put first on convex side, more pack on convex side & remove pack last on convex side. New theory of packing: Septum is in centre so put first on any side, equal packing on both sides & remove both packs together.