Residency · Residency · Otolaryngology

Septoplasty and Nasal Valve Surgery

Overview

Nasal obstruction is one of the most common complaints in otolaryngology. Septal deviation and nasal valve collapse are two major structural causes of nasal airway obstruction. Septoplasty addresses deviated septum, while nasal valve surgery targets the internal and external nasal valves. Understanding functional nasal anatomy and objective assessment tools is critical for appropriate surgical planning and patient satisfaction.

Nasal Septum Anatomy

Composed of cartilage and bone: Quadrangular cartilage: anterior-inferior septum; articulates with the perpendicular plate superiorly and the vomer/maxillary crest inferiorly. Perpendicular plate of ethmoid: superior bony septum. Vomer: posteroinferior bony septum. Maxillary crest and premaxilla: floor of the septum. Anterior nasal spine: bony projection at the base of the piriform aperture. Key relationships: dorsal (keystone area where upper lateral cartilage meets septum and nasal bones), caudal (anterior free edge; determines tip support and columella position).

Nasal Valve Anatomy

Internal Nasal Valve (INV)

Located at the junction of the upper lateral cartilage (ULC) and the nasal septum. Narrowest cross-sectional area of the nasal airway. Normal angle: 10-15 degrees (Caucasians); wider in other populations. Bounded by: ULC laterally, septum medially, nasal floor inferiorly, head of inferior turbinate posteriorly. Narrowing below 10 degrees produces significant obstruction.

External Nasal Valve (ENV)

The nasal vestibule opening; the nostril. Bounded by: alar rim (lower lateral cartilage), columella, nasal sill (floor). Collapse during inspiration = external nasal valve dysfunction. Cottle test: lateral traction on the cheek widens the valve; if breathing improves, valve collapse is likely (low specificity). Modified Cottle maneuver: use a curette or cotton-tipped applicator to support the lateral nasal wall at the internal vs. external valve level to differentiate the level of obstruction.

Indications for Septoplasty

Symptomatic nasal obstruction attributable to septal deviation failing medical therapy (topical steroids, decongestants). Access for FESS (septal deviation blocking endoscopic approach). Septal spur causing recurrent epistaxis or contact headache. Source of graft material (cartilage harvest for rhinoplasty, tympanoplasty). Obstructive sleep apnea (adjunctive to improve CPAP tolerance or nasal airflow). Relative contraindications: active cocaine use, granulomatous disease, unrealistic expectations, pediatric patients (preserve septal growth centers).

Septoplasty Technique

Traditional (Submucosal Resection Approach)

Hemitransfixion incision (or Killian incision): incision through mucoperichondrium on one side of the caudal septum. Elevate mucoperichondrial flap in the subperichondrial plane (avascular plane). Identify and preserve the L-strut: at least 10-15 mm of dorsal and caudal cartilage must remain for nasal support. Remove deviated portions of cartilage and bone (quadrangular cartilage, perpendicular plate, vomer, maxillary crest). Address bony spurs at the vomer-maxillary crest junction with osteotomes or powered instrumentation. Reposition or morselization of cartilage if needed. Close mucosal flaps; quilting sutures to eliminate dead space (reduces hematoma). Splints (internal silicone) placed for 5-7 days.

Endoscopic Septoplasty

Performed entirely under endoscopic visualization. Targeted correction of specific deviation without extensive flap elevation. Useful for posterior or isolated deviations and as part of FESS.

Extracorporeal Septoplasty

For severely deviated septa (S-shaped or multiply angulated). Complete removal of the septal cartilage, straightening ex vivo (scoring, morselization, or suturing to PDS plate), and reimplantation. Technically demanding; risk of resorption.

Complications of Septoplasty

Septal hematoma: collection between perichondrium and cartilage; presents with bilateral nasal obstruction and boggy, fluctuant septum; requires immediate drainage to prevent septal abscess and cartilage necrosis (saddle nose deformity). Septal perforation: from bilateral opposing mucosal tears or cautery; small perforations may whistle; large perforations cause crusting and obstruction; repair with mucosal advancement flaps or interpositional grafts. Saddle nose deformity: loss of dorsal septal support from excessive cartilage removal (L-strut violation) or septal hematoma/abscess. Nasal tip deprojection: caudal septal over-resection. CSF leak: rare; if dissection extends to the perpendicular plate near the cribriform. Numbness of upper incisors: injury to nasopalatine nerve. Adhesions/synechiae: between septum and turbinate.

Nasal Valve Surgery

Internal Nasal Valve Repair

Spreader Grafts

Cartilage strips (usually septal cartilage) placed between the ULC and the dorsal septum. Widen the internal nasal valve angle. Standard technique in rhinoplasty and functional nasal surgery. Can be placed via open or endonasal approach. Typical dimensions: 15-20 mm long, 3-5 mm wide, 1-2 mm thick.

Spreader Flaps (Auto-Spreaders)

The ULC itself is folded inward to create a spreader effect. Avoids need for additional cartilage grafting, Useful when ample ULC is present.

Butterfly Graft

Conchal cartilage graft placed across the dorsum at the internal valve. Creates a spring-like effect to widen the valve, Endonasal or external approach.

Flaring Sutures

Horizontal mattress sutures between ULCs to flare them apart. Simple technique for mild INV collapse.

External Nasal Valve Repair

Alar Batten Grafts

Cartilage grafts (conchal or septal) placed in a pocket lateral to the lower lateral cartilage (LLC). Support the lateral alar wall and prevent collapse on inspiration. Positioned at the point of maximal collapse, Onlay or inlay placement.

Lateral Crural Strut Grafts

Cartilage grafts placed deep to the lateral crus of the LLC. Stiffen and support the lateral crus; prevent pinching or collapse. Often placed via open rhinoplasty approach.

Alar Rim Grafts

Small cartilage grafts placed along the alar rim in a precise pocket. Address alar retraction and marginal collapse.

Nasal Valve Suspension (Latera Implant)

Absorbable polylactic acid implant placed in the lateral nasal wall. Supports the INV and ENV area, In-office or operating room placement. Gradually resorbs over 18-24 months; long-term support from fibrotic encapsulation. Moderate evidence; may be best for mild-to-moderate valve collapse.

Inferior Turbinate Reduction

Often performed concomitantly with septoplasty and/or valve surgery. Techniques: submucosal resection, radiofrequency ablation, microdebrider-assisted turbinoplasty, outfracture, partial turbinectomy. Avoid aggressive total turbinectomy (risk of empty nose syndrome).

Outcomes Assessment

NOSE score (Nasal Obstruction Symptom Evaluation): validated patient-reported outcome measure; 0-100 scale. Acoustic rhinometry: measures cross-sectional area (minimum cross-sectional area at the INV). Rhinomanometry: measures nasal airflow and resistance. Peak nasal inspiratory flow (PNIF): simple, reproducible.

<image>Sagittal cross-section diagram of the nasal septum showing the component structures: quadrangular cartilage (anterior), perpendicular plate of ethmoid (superior), vomer (posteroinferior), maxillary crest (floor), and anterior nasal spine. The L-strut is highlighted with the minimum 10-15 mm dorsal and caudal measurements indicated. The keystone area where the septum meets the nasal bones and upper lateral cartilages is labeled. Sites of common septal deviation (vomer-maxillary crest junction, cartilage-bone junction) are marked.</image>

<image>Cross-sectional diagram of the nose at the level of the internal nasal valve comparing normal anatomy to nasal valve collapse. Left panel: normal internal nasal valve angle of 10-15 degrees between the upper lateral cartilage and the nasal septum, with the inferior turbinate head forming the posterior boundary. Right panel: narrowed internal nasal valve with collapsed upper lateral cartilage causing airway obstruction. A third panel shows the surgical correction with a spreader graft in place between the ULC and septum, widening the valve angle. All structures labeled: ULC, septum, inferior turbinate, nasal floor, spreader graft.</image>

<image>Surgical illustration showing three techniques for nasal valve repair. Top panel: spreader graft placement during open rhinoplasty with cartilage strips being sutured between the upper lateral cartilages and the dorsal septum. Middle panel: alar batten graft placed in a lateral subcutaneous pocket over the area of external valve collapse, with the conchal cartilage graft shape shown. Bottom panel: lateral crural strut graft secured deep to the lateral crus of the lower lateral cartilage to prevent pinching. Relevant anatomical structures labeled in each panel.</image>

Clinical Pearls

The L-strut (dorsal and caudal struts of at least 10-15 mm each) must be preserved during septoplasty; violation leads to saddle nose deformity or tip ptosis. Septal hematoma is a surgical emergency: bilateral boggy septum post-septoplasty must be drained immediately to prevent cartilage necrosis. The Cottle maneuver is sensitive but not specific for nasal valve collapse; use a modified Cottle with an instrument to localize the level of obstruction. Septoplasty alone may not improve symptoms if nasal valve collapse is the primary pathology -- always assess the valve preoperatively. Spreader grafts are the gold standard for internal nasal valve repair; alar batten grafts address external valve collapse. Inferior turbinate reduction is a common adjunct to septoplasty and improves outcomes, but avoid overly aggressive resection. Pediatric septoplasty should be approached cautiously to preserve septal growth centers; limited to symptomatic posterior deviations or severe obstruction when possible. The NOSE score is a validated, simple tool for tracking subjective outcomes pre- and post-operatively.

References

• Stewart MG, Witsell DL, Smith TL, et al. "Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale." Otolaryngol Head Neck Surg. 2004;130(2):157-163.
• Rhee JS, Weaver EM, Park SS, et al. "Clinical consensus statement: Diagnosis and management of nasal valve compromise." Otolaryngol Head Neck Surg. 2010;143(1):48-59.
• Chambers KJ, Horstkotte KA, Shanley K, et al. "Spreader graft placement to improve nasal valve area." JAMA Facial Plast Surg. 2015;17(3):195-199.
• Bloom JD, Sridharan S, Engel A, et al. "Modified Cottle maneuver for nasal valve assessment." Arch Facial Plast Surg. 2012;14(5):365-366.

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