Septoplasty is most commonly indicated when the patients complain of unilateral or bilateral nasal obstruction caused by structurally deviated cartilaginous or bony portions of the nasal septum. Although various surgical techniques have been introduced for correction of septal deviation, success rate for primary septoplasty varies from 43 to 85% [1, 5, 7, 8]. The most common cause of septoplasty failure is residual or recurrent septal deviation due to incomplete correction of the septal deformity [6]. Revision septoplasty may be performed in patients with ongoing nasal obstruction and persisting septal deviation despite prior septoplasty. In this study, patients underwent septoplasty in primary and secondary hospital were more likely to undergo revision septoplasty. The higher failure rate of septoplasty in primary and secondary than tertiary hospital may be attributed to the incomplete correction of septal deviation due to lack of surgical skills or concerns about cosmetic complications such as tip ptosis and saddle nose deformity.
A few studies have described sites of persistent septal deviation after primary septoplasty. Gillman et al. [1] reported that residual deviation was most commonly identified at the dorsal septum. However, Becker et al. [4] found that multiple sites of deviation was the most common in revision surgery, and caudal septal deviation was the second. Another study showed that the middle septum was the most common site of persistent deviation, followed by caudal septum [6]. In the present study, C-shape was more common than S-shape deviation in the anteroposterior and cephalocaudal dimensions by CT findings. Furthermore, the most common area of persistent septal deviation were caudal septum, followed by multiple sites, anterior septum, and middle septum.
Caudal septal deviation is defined as deviation of the anterior most portion of the nasal septum [9]. Caudal septal deviation may be a major cause of nasal obstruction and cause significant cosmetic deformities of the nasal base [10, 11]. Deviated caudal septum may change the lobular and columellar relationship and has a significant effect on tip position and symmetry [10]. However, the correction of caudal septal deviation may be difficult because small residual deviation may cause severe nasal obstruction and the intrinsic cartilage-bending memory is hard to overcome [11]. Furthermore, weakening of the caudal septum and separation from the anterior nasal spine can lead to complications, including overcorrection, saddle nose deformity, and tip ptosis [12]. Although various techniques have been reported to manage caudal septal deviation, this part is one of the most difficult to surgically correct with high septal deviation.
The surgical approach to revision septoplasty can be performed through a standard endonasal approach or open rhinoplastic approach. Many different techniques, such as swinging door method, septal batten graft, spreader graft, cutting and suture technique, and extracorporeal septoplasty have been proposed for correction of residual septal deviation, depending on the septal deviation characteristics and surgeon preferences [6, 13, 14]. Previous studies reported that open approach was more commonly used than endonasal approach [4, 6]. However, 61 (82.4%) patients underwent an endonasal approach and 13 (17.6%) underwent an open approach in this study. To correct remnant septal deviation, careful excision of remnant deviated cartilaginous or bony portion was most commonly performed. Septal cartilage traction suture technique introduced by Seo et al. [15] was applied in 20 cases and crossing suture technique described by Joo et al. [16] was used in 5 cases of the deviated caudal septum. Spreader graft was done in 10 patients to correct the deviation of anterior septum reaching dorsum, which was accomplished by the open approach. Our revision septoplasty techniques significantly improved subjective symptoms measured by VAS scale score for nasal obstruction. Furthermore, objective improvement in nasal obstruction was measured with acoustic rhinometry. MCA and nasal cavity volume in the convex side were significantly increased at 6 months postsurgery. However, the MCA and nasal cavity volume of the concave side was also increased, which is thought to be due to volume reduction of the inferior turbinate.
Although this study has the inherent limitations of a retrospective review, we believe that our prospectively collected data composed of validated outcome measurements do offer further support to the benefit of revision septoplasty in patients with persistent nasal obstruction following septoplasty. Additional well-designed randomized controlled prospective studies are needed to confirm our findings.