• Embryology
  • Anatomy
  • Pathologic Anatomy Of Cartilage
  • Indications For Nasal Septal Surgery
  • Techniques Of Septal Surgery
  • Sequence Of Techniques In Septorhinoplasty
  • Complications Of Septal Surgery

Septoplasty History: first made in 1757 with Quelmaltz's daily digital pressure for gradual correction.

Adams (1875) advocated fracture and splinting of the nasal septum.

Ingals 1882 removing a small triangular piece of cartilage

Hinderer, 1971). Krieg (1889) Boeninghaus (1900): removing deformity & nasal mucosa.

Asch (1899) altering the spring of the cartilage with full-thickness cruciate incisions.

Freer (1902) and Killian (1904) concepts of submucous resection (SMR)

Metzenbaum (1929), Metzenbaum's "swinging door" technique

Cottle (Cottle and Loring, 1947) septoplasty methods.


-development of nose begins week 3 of fetal development

-starts with thickening of cranial ectoderm (precursor of paired olfactory placodes)

-5th week, Þ lateral and medial nasal swellings appear as ridges surrounding the placodes,

which become depressed to form epithelium-lined nasal pits (Moore, 1973).

-deepening of these pits separates the frontonasal process into medial and lateral

-medial component fuses to form primitive nasal septum.

-inferiorly, the paired maxillary processes of first branchial arches grow anteriorly and medially to fuse with the medial nasal processes.

-6th week;Þ nasal pits extend posteriorly & form bucconasal memb (separates nasal & oral) Subsequent membrane rupture forms choanae.

Þ nasal septum, grows simultaneously toward sphenoidal process in post direction.

-3rd fetal mnth; mesenchymal condensation begins & cartilage grows in from sphenoid to

form two adjacent plates which fuse with one another & also ventrally with

lateral nasal walls to form the nasal capsule.

-5th month, & well into adolescence, ossification of posterior part of cartilaginous capsule nb: -perpend plate of ethmoid remains fibrous until 3rd year, then ossifies

-vomer, develops from CT astride septal cartilage not by ossification of cartilage

-6th fetal month, ingrowth of connective tissue divides capsule into lower & upper lateral cartilages as well as septal cartilage.

Nasal septum:

-made up of:

-bony: parts of maxillary, palatine, vomerine & ethmoid bones,

nasal spine of frontal bone & premaxilla

-cartilage: Quad cartil, upper lateral cartilages, membranous septum, & columella

Maxillary crest: F’d by perpendicular projections from maxilla and palatine bone.

-In its groove lies quadrilateral cartilage anteriorly and vomer posteriorly.

-Cartilage articulates via fibrous attachments (occasionally, fat is interposed)

-articulation b/w vomer and maxillary crest is fibrous early in life, & becomes bony after both structures have ossified

Septal cartilage:

-four borders: dorsal, ventral, caudal, and cephalic (see Fig. 46-1).

-most caudal portion:

-extends beyond (anterior to) nasal spine (to which is attached +++).

-is insinuated into posterior aspect of columella, b/w two medial crura.

-cephalic border:

-where it lies against perpendicular plate is the thickest (5-7 mm) part of septal cartilg. -cephalic extent varies considerably, & can reach beyond midpoint of the nasal bones.

-septal cartilage articulates with upper lat cartilages at the rhinion (Fig. 46-4).

-dorsal edge of septal cartilg has a groove that cephalically accepts nasal spine of frontal bone, and just caudally, the keel-like undersurface of the nasal bones (Fig. 46-4).

nb: these form the keystone area of nasal support, (structure of substantial strength)

-nb: -no relationship between thickness of septal cartilage and perpendicular plate.

-upper lateral cartilages & septum are separate cartilages, housed in own compartments (serves to tamponade and localize bleeding)

-septal fractures are usually confined to the free nasal tip and are vertically oriented.

-fractures may occur in an oblique fashion and can extend from nasal spine to rhinion

A, Through upper lateral cartilages; B, at rhinion (keystone area); C, root of nose (also radix).

Perpendicular plate of the ethmoid bone (perpendicular lamina).


-descends downward from cribriform plate

-makes up large part of nasal septum.

-contribution to nasal support is minimal.

-chief significance is related to its presumed role in shock absorption.

-anterior border is grooved to receive nasal process of frontal bone & the joined nasal bones.

-caudal edge: thickened where it lies against septal cartilage.

-lower edge curves sharply as it lies in groove on superior surface of vomer.

Mucoperiosteal and mucoperichondrial linings:

-contains its blood and nerve supply (ie b/w perichondrium & overlying mucosa)

nb: vessels run in an anteroposterior direction along the septum


Causes of bent cartilage:

i. congenital disproportion, (ie cartilaginous component is too large for housing in which it grows

nb: as it bends, it generates intrinsic tension.

ii. long-term results of trauma sustained earlier in life (more common cause).

-usually resists many episodes of trauma because of its elasticity.

BUT even minor trauma to the developing nose Þ significant effects on development

-3 distinct periods in early development of nose (Hinderer 1971):

-first period lasts for 5 years and is distinguished by rapid growth,

-next 5 years are noted for relative quiescence,

-last 5-year period is associated with another acceleration of growth.

-neonatal period trauma:

-most nasal deformities in newborns occur during labor or birth

-nb: cartilaginous nasal tip is most prominent facial structure by 2-3cm

-early life trauma to septum results Þ gradual bowing and deviation of cartilage,

Þ asymmetric growth of nose, septal membranes, and underlying skeletal parts.

-majority of microfractures occurring early in life are vertically oriented.

-Steiner (1959): nasal trauma may occur at any time after fourth month of gestation.

-Cottle (1951):distinction b/w temporary nasal flattening from delivery VS permanent damage in-utero b/c nasal septal deformities are sometimes noted in neonates born by cesarean

Intrinsic factors

-In vitro studies Þ cartilage has definable intrinsic stress system & if disturbed by fractures,

Þ an imbalance that can lead to warping or bending.

-Histological explanation:

-chondrocytes are concentrated at periphery of cartilage, whereas central portion is acellular.

-if one side of cartilage is interrupted with partial-thickness cuts (or a microfractures from early life) Þ opposite side assumes dominance, Þ warping of cartilage in that direction (Fig. 46-5).

Then as fibrous ingrowth fills the microfracture, permanence is established.

-nb: magnitude of these stresses vary in different areas of septum, as well as b/w different septums.

\ partial cuts are good in some areas of cartilage but not others. (?? need for full-thickness cuts)

A, Partial cuts leading to, B, convex bending.

C, Counteracting partial-thickness cuts on opposite side, Þ equalizing peripheral dominance

D, Note chondrocyte concentration on periphery of cartilage & relative acellularity in center.

Extrinsic factors

-premaxillary spine (abN’lly large/lateralized) can Þ displacement of base of caudal septal cartilage

-maxillary crest-vomer relationship abnormalaty also can Þ displacement of nasal septum.

nb: spurs can be due to:

-distorted appearance of normal bony anatomy.

-vomer is actually fractured, leaving its lower edge lying in the groove of the maxillary crest.

-perpendic plate of ethmoid deformity can Þ marked deviation of junction area with septal cartilg.

-previously depressed nasal bone

-upper lateral cartilage assymetry

-any lateral nasal structure (e.g., a turbinate) can disproportionally impinge on nasal septum


-nasal "valve" (Mink 1903)

-space b/w most caudal margin of upper lat cartilage & nasal septum.

-this angle is apprx 10-15 degrees, (if > 15 Þ prob with N functn).

-controls "shape" (change from columnÞ sheet), resistance & velocity of inspired air currents

-resistance of nasal valve results in a greater depth of respiration (Hinderer, 1971).

-area can be disturbed by deviation of nasal septum or by bowing effect of a flattened nose -velocity of airflow must be within a critical zone; if too fast/slow, valve collapses against septum.

-certain resistance is necessary for the air conditioner, and filter to work well.

(air in nasopharynx is maintained at temp of 30°-37° C with 75% or greater relative humidity)

-in quiet respiration nose accounts for 50% of total airway resistance (nasal valves make up most)


-elective surgical procedures,\ no absolute indications, only relative.

influenced by age, economic status, and social and environmental needs.

-2 categories of indications: procedures for primary abnormalities & those associated with rhinoplasty.

I. Septal surgery for primary septal pathology

Nasal obsrtuction:

-Nasal obstruct’n is subjective (??snoring, mouth breathing, dryness of pharynx, watch pt breathe)

-Rhinomanometry used to quantify nasal airflow,(?? role in preop evaluation)

-other med probs (eg chronic lung disease)

-Athletes (?? musicians ..ZB) better performance with functional nasal breathing vs oral only.

-Nasal obstrctn has been assoctd with hypoxia, ß ‘d pulmonary function, sudden death, sleep apnea

-Exercise-induced asthma is related to pulmonary ambient temp & humidity; \ improvement in nasal breathing secondary to septoplasty has been shown to improve this condition

-alterations in airflow currents result. Þ drying, crusting, and metaplastic changes of mucosa on the side with increased flow.


-abnormal air turbulence secondary to intranasal deformity Þ excessive mucosa drying & crusting Þ recurrent bleeding.

-septoplasty for access to bleeding site.

Sinus drainage

-if deviated nasal septum impinges onOMC

II Septal surgery as part of functional or cosmetic rhinoplasty


Contemporary methods: emphasis on straightening septal cartilage rather than removing it.

Correcting extrinsic defects

-elevate membranes one or both sides & inspect overall pathology,

-separate septal cartilage from most of its bony attachments, and,

-expose postr part of nose(ie perpendic ethmoid plate& vomer) by displacing cartilage to one side

-posterior deformities are managed by removing bone.

-septal cartilage is then altered in a manner dictated by the problem at hand.

-to ensure a narrow septal base and allow the cartilage to seek midline freely, a large portion of

vomer and maxillary crest is often removed.

-anterior maxillary spine is almost always preserved as its periosteum provides a sturdy tissue to which the septal cartilage, which is now free, is reattached.

Steps of dissection

- incision: a hemitransfixion incision, at caudal rim of septal cartilage.

-dissection into subperichondrial plane

-sharp dissection against bone of crest to enter subperiosteal plane elevate off floor.

-separation of septal cartilage from bone of perpendicular plate and is carried down to vomer and forward along it to anterior maxillary spine. -boomerang-shaped piece of cartilage is excised along edge of cartilage.

-septal cartilg should then swing freely with opp mucoperichond flap intact.."swinging door"

-door is displaced laterally with speculum, & bony septum can be inspected +/- removed

-chisel is used to cut maxillary crest along floor, starting just posterior to ant maxillary spine

-a bone scissors is used to cut the perpendicular plate superiorly avoiding #of cribriform plate

-remaining portions of deviated ethmoid plate and vomer can then be removed.

-Attention is then directed to the cartilage that is the "swinging door.":

If it is straightÞ suture base of caudal septum to periosteum of antr maxillary spine.

- If deviated,

-if old # line filled with fibrous tissue is seen, # line & adjacent cartilage is excised.

-if deviation is more complex:

-partial-thickness cutting of cartilage on concave side to make it straighter.

-full-thickness incisn on concave curvature or wedge excisin on convex surface

-morselization, or "checkerboard" gridding

-sometimes necessary to elevate both mucoperichondrial membranes.

nb; elevation of both membranes totally deprives cartilage of blood supply

-cartilage grafts have been used.

-crushed cartilage replaced.

-membrane-approximation with 4-0 plain catgut (ie thru & thru quilting suture).

-incision is closed.

-packed to prevent hematoma and for support.


Hematoma & Hemorrhage

-potentially serious complication.

-cartilage deprived of its blood supply can be absorbed.

ß metabolic activity of cartilage begins promptly after separation from its blood supply.

-unless infected cartilage stays alive for about 3 days, \ needs Rx in < 3 days!!!

-after 3 days at body temperature, chondrocyte death results Þ absorption

-Chondrocytes make chondromucoprotein, collagen, elastin, and the matrix around it.

-?? pressure from expanding hematoma within a perichondrial pocket enhances absorption.

-infection puts cartilage at increased risk for resorption.

-If septal hematoma remains uninfected, the clot proceeds to liquefaction.

Partial or complete resorption of hematoma ensues +/- fibrosis Þ permanent thickening of septum

-If septal hematoma becomes infected Þ substantial if not total cartilaginous absorption follows.

Þ classic saddle deformity, due to loss of septal structure & scar contracture.

-causes: -failure to adequately obliterate intramembranous dead space

-bleeding from bone edges in floor.

-clin: -swelling and pain. (nb: intense pain does not occur after septoplasty; if it does, ??hematoma)

-excessive swelling of upper lip and mucosal discoloration under the upper lip.(results from intramembranous blood collection and subsequent dissection into tissues adjacent)

-complete nasal obstruction.

-Mx: -prompt.

-drainage through previously made transfixion incision +/-drain.

nb: Needle aspiration of localized pockets of partially clotted blood may be adequate) -following evacuation Þ intranasal packing and antibiotics.


-infection following septoplasty is unusual.

Nasal obstruction

-after postoperative swelling has subsided, continued nasal obstruction is usually related to:

scar formation (adhesions) or turbinate hypertrophy.

-scar bands are usually small and can be corrected in the office with LA and transection.

-nb: the compensatory pre-op hypertrophy of inf or mid turbinate on concave side of septum, can be a

problem post op if not Rx’d at Sx.

Septal perforation

-When tears occur bilaterally and opposite one another, potential for postop septal perforation exists.

-Under such circumstances, reapproximate mucosal edges with sutures on at least one side & place a

piece of intervening cartilage between the membranes.

-Post-operative infection, excessive packing, hematoma, tight membrane-approximation sutures

can Þ vascular compromise and subsequent septal perforation.

Palatal and dental anesthesia

Clin: temporary anesthesia of medial incisor teeth & immediately adjacent palatal mucosa.

Due to: transection of delicate nerve endings in area of premaxilla

This anesthesia is usually short lived.


Alteration in ability to smell has been reported but is very unusual.

Cosmetic nasal deformity

-following excessive removal of nasal septal cartilage.

-When removal of substantial amounts of septal cartilage is necessary, every attempt should be made

to place straightened cartilage back into the surgically created dead space.


Cottle M: Nasal surgery in children: effect of early nasal injury, EENT Monthly 30:32, 1951.

Cottle M: Concepts of nasal physiology as related to nasal surgery, Arch Otolaryngol 72:11, 1960.

Cottle M, Loring R: Corrective surgery of the external nasal pyramid and the nasal septum for restoration of normal physiology, EENT Monthly 26:147, 1947.

Cummings, C. Otolaryngology. 

Gates G, Current Therapeutics.