Persistent Septal Deviation After Septoplasty: Causes and Surgical Management

Abstract

Purpose: Septoplasty is one of the most common surgical procedures performed by otolaryngologist. There are various causes of persistent septal deviation after primary septoplasty. The purpose of this study was to identify the associated factors affecting the failure of the primary septoplasty, and to investigate operative techniques for correcting residual septal deviation, as well as surgical outcomes.

Methods: Seventy-four adult patients underwent revision septoplasty for persistent septal deviation was included. The level of hospital where primary septoplasty was performed, type of septal deviation, persistent deviated septal portion, and techniques used to correct the residual deviation were evaluated. Subjective outcomes using visual analog scale (VAS) and acoustic rhinometry data were assessed.    

Results: The first septoplasty was performed mainly in primary and secondary hospital. C-shape was more common than S-shape deviation in the anteroposterior and cephalocaudal dimensions. The most common areas of persistent septal deviation were caudal septum (44.6%) followed by multiple sites (20.3%). Correcting techniques included excision of remnant deviated portion (70.3%), septal cartilage traction suture (27.0%), spreader graft (13.5%), and crossing suture (6.8%). There was significant symptomatic improvement in the VAS at 6 months postsurgery. The minimal cross-sectional area and nasal cavity volume of the convex side were significantly increased after revision septoplasty.      

Conclusion: The patients underwent septoplasty in primary and secondary hospital were more likely to undergo revision septoplasty. Caudal septum was the most common sites of persistent septal deviation. Preoperative careful evaluation for caudal septal deviation characteristics and selection of the appropriate surgical techniques may lead to reduction of the need for revision septoplasty.

Introduction

Nasal obstruction is one of the most common symptoms which otolaryngologist may encounter during general practice. Although there are various etiologies for nasal obstruction, a deviated nasal septum is the most common cause of unilateral nasal obstruction [1]. It may cause difficulty breathing, frequent nosebleeds, repeated sinus infections, headaches, snoring, sleep disturbance, and worsening sleep apnea [2]. Various septoplasty techniques have been proposed to deal with the distinct sites of septal deviation. Septoplasty can be performed via an endonasal approach or open rhinoplasty approach.

Septoplasty is one of the most common surgical procedures performed by otolaryngologist [3]. However, more than 15% of patients who underwent primary septoplasty fail to relieve their symptoms [1, 5]. Persistent nasal obstruction after septoplasty may be attributed to the unrecognized nasal valve compromise, inappropriate management of turbinate hypertrophy, aggravation of allergic rhinitis, and residual or recurrent septal deviation [6]. However, incomplete correction of the septal deviation has been known as the main causes for persistent septal deviation after primary septoplasty.

This study examines our institution’s long-term outcomes of revision septoplasty in a population of persistent nasal obstruction following septoplasty. We assessed the associated factors affecting the failure of the primary septoplasty, surgical techniques for correcting residual septal deviation, and postoperative outcomes using subjective symptoms and acoustic rhinometry.

Subjects And Methods

Results

A total of 74 patients were enrolled in the study, including 66 males and 8 females from 18 to 70 years of age, with mean age of 37.5 years. The unilateral nasal obstruction was 39 (52.7%), and the bilateral obstruction was 35 (47.3%). The first septoplasty was performed in the primary (32/74, 43.2%), secondary (32/74, 43.2%), tertiary (10/74, 13.6%) hospital. The interval between primary and revision septoplasty was 11.30 ± 5.82(range 1 ~ 39) years. Sixty-one patients (82.4%) received revision endonasal septoplasty and 13 patients (17.6%) received revision septoplasty with rhinoplasty using an external approach. Inferior turbinate out-fracture and turbinoplasty were combined in 45 patients (73.8%) of septoplasty and in 5 patients of septorhinoplasty (38.5%). Only one patient showed postoperative complications such as septal perforation during 6 months follow-up. The patients’ characteristics are summarized in Table 1.

Anteroposterior C-shape deviation was shown in 59 patients (79.7%) and S-shape deviation in 15 patients (20.3%). In cephalocaudal dimension, 65 patients (87.8%) had C- shape deviation and 9 patients (12.2%) had S-shape deviation. The most common locations of persistent septal deviation were caudal septum (44.6%), followed by multiple sites (20.3%), anterior septum (14.9%), middle septum (12.1%), posterior septum (6.8%), and maxillary crest (1.3%) (Table 2). Correcting techniques included excision of remnant deviated portion (70.3%), septal cartilage traction suture (27.0%), spreader graft (13.5%), and crossing suture (6.8%) (Table 3).

Symptomatic VAS scores for nasal obstruction significantly decreased from 7.84 ± 1.92 to 2.70 ± 2.62 at 6 month postoperatively (p < 0.001). The mean MCA and nasal cavity volume of the convex side were significantly increased from 0.39 ± 0.24 cm² and 5.38 ± 2.20 cm³ to 0.66 ± 0.19 cm² and 8.04 ± 3.57 cm³ at 6 months postsurgery, respectively (p = 0.002 and p = 0.025, respectively). However, there were no significant difference in the mean MCA and nasal cavity volume of the concave side between the preoperative and postoperative scores (Table 4).

Discussion

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.

Conclusion

The patients underwent septoplasty in primary and secondary hospital were more likely to undergo revision septoplasty. Incomplete correction of the caudal septal deviation was the main reasons for persistent septal deviation after primary septoplasty. Therefore, careful evaluation for caudal septal deviation characteristics and selection of the appropriate surgical techniques at the primary surgery may lead to reduction of the need for revision septoplasty.

Declarations

Conflict of interests

The authors declare that they have no competing interests.

Financial Disclosure

The authors did not receive support from any organization for the submitted work.

human ethics statement

All methods were carried out in accordance with relevant guidelines and regulations

Informed consent was waived by the Institutional Review Board of Pusan National University Hospital (H-2105-007-102)

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