Armando Boccieri - Gobba Nasale
NASAL SEPTUM DEVIATION
NASAL SEPTUM DEVIATION

In this pathological situation the septum does not follow the median line between the two nasal cavities but is deviated to one or both sides, thus constituting a monolateral or bilateral obstruction to nasal respiration. The deformity can be congenital or acquired. In the first case, the curve of the septum is due to the uneven development of its constituent osseous structures (vomer, ethmoid, maxillary and palatine bone). In the second, the cause is often a traumatic event, possibly combined with fracture of the nasal bones, resulting in external deviation of the nasal pyramid. In addition to varying degrees of obstruction of the nasal airflow, patients can experience recurrent sinusitis, pharyngitis, laryngitis and otitis. All these inflammatory phenomena are the result of deficient airflow through the nose and can become chronic over the years with increasingly serious and problematic symptoms.

It is sometimes easy for the specialist to formulate a diagnosis solely through examination of the nasal base revealing deviation of the septum in one of the nostrils. Rhinoendoscopy makes it possible in all cases to specify the deviated portions of the septum through direct observation as well as the presence or otherwise of osseous and/or cartilaginous basal spurs and their possible conjunction with turbinate hypertrophy. A CT scan of the facial skeleton can prove useful to obtain a broader diagnostic picture capable of highlighting further associated details and pathologies such as obstruction of the maxillary ostiomeatal complex and chronic sinusitis.

In accordance with the modern therapeutic vision, the operation of septoplasty must seek to preserve the structures and avoid any weakening of the nasal pyramid. Removal of the deviated portion must therefore in any case leave an L-shaped structure capable of supporting the nasal dorsum and tip.

 



CT scan of the skull showing deviation of the nasal septum to the left with turbinate hypertrophy

          

 

 

 

 

                         

 

             

L-shaped supporting structure that always must be left intact after removal of the deviated septum in order to avoid collapse of the nose

In cases where this structure is also deviated, it can be realigned by means of an autograft of septal cartilage and reshaping techniques. It should be noted that overly aggressive septoplasty with weakening of this support is sometimes the cause of drooping tip and saddle deformity, which then require revision septorhinoplasty for correction.

The removal of septal basal spurs and decongestion of enlarged turbinates often become necessary during the operation too, as both contribute to impaired respiration. The two flaps of mucosa detached in order to expose the septum are reattached to one another by means of a special suture inside the nose that stops bleeding and prevents it from occurring after the operation. This recently developed procedure often makes it possible to avoid nasal packing or reduce it to a maximum of 3–4 days, and in any case to use light packing soaked in emollient cream. It should be noted in this connection that this technical progress also makes it possible to remove packing from the nose with no discomfort for the patient, unlike what happened in the past.

                                                   

             Deviation of the nasal septum to the right                  Postoperative result

 
COLLAPSE OF THE NOSE CAUSED BY SEPTOPLASTY

The 19-year-old patient complained of impaired nasal respiration and collapse of the tip after an operation to correct deviation of the septum.
During clinical examination, pressure on the nasal tip revealed the complete loss of support for the lower two-thirds of the nasal pyramid due to the total removal of the cartilaginous septum incorrectly carried out in the previous operation. Observation in profile revealed a drooping nasal tip and particularly acute nasolabial angle.

                              

     


The operation of reconstructive septorhinoplasty performed involved the insertion of a suitably sculpted graft of cartilage from the auricular concha to replace the removed portion of the nasal septum and provide the necessary support.


I published this case in 2006 in the article ‘Septal Considerations in Revision Rhinoplasty,’ Facial Plastic Surgery Clinics of North America, 2006, 14(4), pp. 357–71.

 
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