Deviated Nasal Septum and Septoplasty

A deviated septum is one of the commonest structural causes of a blocked nose. The septum itself is the midline partition of the nose, part cartilage and part bone, and when it bends far enough it obstructs airflow, dries the mucosa, and can throttle sinus drainage. Four things are worth getting straight: its framework, why it deviates, how to confirm the deviation is actually what is blocking the nose, and the principle that keeps septoplasty safe — leave enough cartilage behind to hold the nose up.

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Septal anatomy

The septum is built from a cartilaginous front and a bony back:

• Quadrangular (septal) cartilage — the anterior cartilaginous plate.
• Perpendicular plate of the ethmoid — posterosuperior bone.
• Vomer — posteroinferior bone.
• Maxillary crest and the nasal spine — the inferior bony foundation the septum sits on.

The cartilage and bone are clothed on each side by a tough mucoperichondrial / mucoperiosteal layer — the plane surgeons elevate to work on the framework while keeping the lining intact.

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Types and causes of deviation

Patterns

• Caudal deviation / dislocation — of the anterior (caudal) cartilage; a common cause of obstruction and cosmetically visible.
• Septal spur — a sharp bony-cartilaginous projection, often at the maxillary crest, causing inferior obstruction (and sometimes contact-point headache or epistaxis).
• Bony vs cartilaginous — deviation may sit in the cartilage, the bone, or both.
• Post-traumatic fracture — displaced cartilage or mucosal tears after injury.

Causes

• Trauma — blunt injury (assaults, accidents) is a major cause; birth/fetal trauma can produce significant neonatal deviation.
• Developmental — disproportionate growth of the septal components against a fixed bony frame produces deviation without a clear injury.

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Clinical presentation

• Nasal obstruction — classically constant and unilateral (toward the convex side).
• Compensatory inferior turbinate hypertrophy — on the opposite (concave) side, which can then obstruct that side too.
• Recurrent epistaxis — from mucosal drying over the deviated, exposed cartilage.
• Sinus effects — deviation can obstruct the middle meatus and contribute to sinus disease.
• Smell, taste, and voice — chronic obstruction may dull smell and taste and alter vocal resonance.

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Assessment

• Anterior rhinoscopy — identifies obvious anterior deviations, spurs, and turbinate state.
• Nasal endoscopy — rigid or flexible; confirms the findings, evaluates the posterior septum, and excludes polyps or a tumour masquerading as “just a deviation.”
• Cottle’s manoeuvre — lateral traction on the cheek (or support of the internal valve with a cotton swab) that opens the nasal valve; improvement suggests nasal-valve collapse is contributing, which changes the operation.
• CT — reserved for when another anatomical cause or sinus disease is suspected.

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Septoplasty

Indications — anatomical nasal obstruction from a deviated septum; as part of nasal-fracture repair; and access/control in severe or posterior epistaxis.

Principles of the operation

• Work is carried out in the mucoperichondrial plane: a transfixion incision is made and a mucoperichondrial flap elevated off the cartilage.
• The deviation’s “memory” is released by scoring the cartilage or creating a swinging-door — removing a 2–3 mm inferior strip so the cartilage can be repositioned to the midline.
• Dead space is closed with a running quilting suture (or splints) to appose the mucosal flaps and prevent haematoma.

The rule that prevents disaster: always preserve a supporting dorsal and caudal strut of cartilage (at least ~1 cm). Over-resection of this strut removes the support the nasal dorsum and tip depend on, and is a classic route to a saddle-nose deformity.

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Complications

• Septal haematoma — a bulging, boggy septum after surgery or trauma. It must be drained urgently: untreated it can progress to septal abscess, cartilage necrosis (and saddle-nose), and — rarely — cavernous sinus thrombophlebitis. Quilting sutures or splints help prevent it.
• Septal perforation — from opposing mucosal tears, aggressive bilateral cautery, or systemic disease (e.g. granulomatosis with polyangiitis); presents with crusting, whistling, and bleeding.
• Saddle-nose deformity — a late collapse of the dorsum from loss of cartilaginous support (excessive resection, untreated haematoma, or GPA).

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Frequently Asked Questions

Does everyone with a deviated septum need surgery? No. A deviation only warrants treatment when it causes symptoms, typically constant unilateral obstruction, that fail conservative measures. Many people have an asymptomatic deviation and need nothing. Septoplasty is offered when the deviation is demonstrably the cause of the obstruction.

How is septal deviation shown to be the cause of the blockage rather than something else? By examination: anterior rhinoscopy and nasal endoscopy locate the deviation and, importantly, exclude other causes such as turbinate hypertrophy, polyps, or a tumour. Cottle’s manoeuvre helps identify a coexisting nasal-valve collapse, which needs a different repair.

Why must a cartilage strut be left during septoplasty? Because the dorsal and caudal cartilage supports the shape of the nose. Removing too much (leaving less than about a 1 cm strut) removes that support and can lead to a saddle-nose deformity — a collapse of the nasal bridge. Modern septoplasty repositions and conserves cartilage rather than resecting it wholesale.

What is a septal haematoma and why is it an emergency? It is a collection of blood between the septal cartilage and its lining, usually after trauma or surgery, seen as a bulging septum. The cartilage gets its blood supply from that lining, so an untreated haematoma starves and destroys the cartilage — leading to abscess and saddle-nose. It needs prompt drainage.