Caudal Septal Deviation: New Classification and Management Strategy

Abstract

To propose a classification of anatomical variation of the caudal septal deviation and propose strategy for the management of caudal septal deviation by septo-rhinoplasty and to evaluate the efficacy of treatment of different types of caudal septal deviation in terms of aesthetic and functional outcome. The study is a retrospective review of 124 cases with significant anterior caudal deviation causing aesthetic and or functional problems, treated by septo-rhinoplasty within a 5 year period from December 2014 to December 2019, with a minimum follow up of 6 months. Visual analogue scale, photographic evaluation and subjective assessment were used for postoperative outcomes. Significant improvement in the treatment of nasal obstruction was achieved, with mean visual analogue scale score of 7.83 preoperatively to 3.56 postoperatively, Subjective assessment showed marked satisfaction in 96 patients, moderate satisfaction in 21 and no improvement in seven patients of total 124 patients. The rate of revision was (4%). A novel classification of anterior caudal septal deviation is proposed with surgical technique directed for individual deformity and we have achieved very good results.

Introduction

The inferior border of caudal septum has well-developed processes and rests on the correspondingly flared-out wings of the premaxillary bones. This connection is alterable & related to the caudal deflections. Deflections of the caudal end and dislocations of the postero-caudal septal angle of the septum result in direct airway obstruction at the nasal vestibule and airway collapse.

Caudal septal deviations cause more cosmetic and functional problems than do other types of septal deviations. The severity of a caudal septal deformity or deviation can result in varying levels of nasal obstruction.

The correction of caudal septal deviation remains a challenge for practising otolaryngologist, very often not addressed properly or done half-heartedly for risk of nasal tip drop. The first description of a treatment for a caudal septal deviation was Metzenbaum’s “swinging door” method, which was published in 1929 [1].

Several classifications have been proposed for internal deviation of the nasal septum, based on clinical examination [2] or radiological findings [3]. The most popular classification of internal septal deviation based on endoscopic examination by Bauman and Bauman [2], where septal deviation has been classified in 6 different types.This helps us in understanding of the anatomy of the nasal septum in different types of patient. Here the caudal septal deviation has been included as a part of the classification.While the classification helps in management of several types of septal deformities but provides limited knowledge of management of the caudal septum.The classification in this study will help in understanding the clinical anatomy of a deviated caudal septum and provide strategy for management in each different category.

Material and methods

The medical records of 124 patients with significant caudal septal deviation causing aesthetic and or Functional problems, operated within a 5 year period from December 2014 to December 2019, with a minimum follow up of 6 months were retrospectively reviewed.

Patients with complaints of nasal obstruction due to isolated deviated septum were only included in this study. Patients having nasal obstruction because of deviated nasal septum associated with turbinate hypertrophy and chronic rhinosinusitis were excluded from study.

Photographs were reviewed to determine the severity of caudal deviation and the deviations were then classified into 4 types with different surgical techniques for each type.

Post-operative results were assessed using post-operative photographs, visual analogue scale and subjective assessment.

Proposed Classification

Type A Dislocation of caudal length with excess length coming out of one of the nostrils or excess length bending on itself, causing visible external deformity.

Type B “C- shaped” deviation of the caudal end because of excess anterior posterior length causing bending of the septum in one or both nostrils.

Type C Swing door caudal septal deviation, where the internal septum is in midline or mild deviation and the caudal septum is angulated causing deformity and obstruction.

Type D Complex caudal septal deviations including “S-Shaped” deviation.

Surgical Techniques-

Type A

After giving a Hemi-trans fixation incision and elevating the mucoperichondrium flaps from both sides of the nasal septum, Excess length of caudal septum is judiciously trimmed. The bony cartilaginous attachment is dislocated and a strip of septal cartilage from the posterior part is harvested.

If there is any posterior bony deviation the deviated part is corrected by excising it, now, the upper lateral cartilage is cut from the dorsal septum on the deviated side. Unilateral expander graft on the side of deviation is placed and is fixed with 4-0 PDS suture.

A drill hole is made in the nasal spine by a rotating burr or piezotome needle and the mobilised septal cartilage is anchored with the maxillary spine in midline or the opposite side and is fixed with a 4-0 PDS suture.

Excess length of muco-perichondrium on the deviated side is trimmed, muco-perichondrium flaps are reposited back and Merocele packs are kept for 48 h (Fig. 1)

Fig. 1.

a Deviated anterior caudal nasal septum, b septum after raising muco-perichondrium flaps, c trimming of excess caudal septum and unilateral spreader graft, d preoperative image of dislocated septum, e post-operative image at 2 year follow up

Type B

The C-shaped caudal deviation is part of total septal deviation and it is usually because excess length of the septum which curves it in one of the nostrils.

The options available to the surgeon for correction of the “c-deformity” is to excise a strip of excess cartilage, we use the cartilage overlap technique to correct the c-deviation, Muco-perichondrium is elevated on both sides of deviation, full thickness incision is given over the cartilage dividing it in two segments, it can be done horizontally or vertically depending on the nature of the deviation, the excess of cartilage is overlapped and fixed with horizontal matters suture of 4-0 PDS.

The septum is stabilised by fixation with anterior nasal spine in midline or on the opposite side of the deviation after making a drill hole in the spine by a rotating burr or piezotome needle. Flap reposited back and Merocele packs are kept for 48 h (Fig. 2).

Fig. 2.

a Exposed caudal nasal septum, b trimming of septum, c horizontal overlay, d vertical overlay, e pre operative image showing C shaped deviation, f post operative image on follow up

Type C

The swing door type of deviation it is the most common variety of the caudal deviation.

Steps:

After an open rhinoplasty exposure, muco-perichondrium flaps are elevated on both sides, the septal deviation is exposed in horizontal plane.

A small strip of cartilage at the side of angulation is incised and removed, the caudal septum is mobilised by dislocating it from the anterior nasal spine.

If there is a bending of excess septal cartilage in the posterior part of septum the excess cartilage is excised. The caudal septum is completely mobilised & straightened, excess cartilage may be excised at the caudal end if required.

The two segments of septal cartilage at the site of angulation are fixed together either by overlapping to mask the excess length or by using a piece of ethmoid bone as batton graft.

A drill hole is made in the anterior nasal spine and the straightened septum is fixed with spine to move it in midline (Fig. 3).

Fig. 3.

a Swing door type of deviation, b anterior nasal spine, c fixation of septum to spine, d newly formed straight septum, e pre-operative image showing swing door type of deviation, f post operative image on follow up

Type D

Complex caudal septal deviations including “S-Shaped” deviationare difficult to correct and needs a extracorporeal septoplasty.

Steps:

After an open rhinoplasty exposure and elevation of muco-perichondrium on both sides, the whole septum is removed.

The deviation is corrected and a frame to reconstruct the dorsal and caudal support is made.

The frame is firmly fixed in the key area and nasal spine which is key to the technique and avoids future complications of supra-Tip saddling (Fig. 4; Table 1)

Fig. 4.

a S shaped deviation, b extracorporeal septoplasty, c fixed newly formed septum, d pre operative image showing S shaped deviation, e post-operative image on follow up

Table 1.

Type of deviation and surgical technique

Type of dislocation	Surgical procedure
Type A Dislocation of caudal septum with excess length on one side	Trimming of excess caudal cartilage and Splinting with Unilateral expander graft
Type B “C” shaped deviation	Horizontal or vertical cartilage overlap technique
Type C Swinging door caudal septal deviation	Swinging door or modified swinging door technique with fixation of caudal end to anterior nasal spine
Type D Complex caudal septal deviations including “S-Shaped” deviation	Extracorporeal septoplasty Fixation of the frame to keystone area and nasal spine is most important

Results

A total of 124 patients having caudal septal deviation associated with nasal obstruction and/or aesthetic problem were included in the study with a minimum follow up of 6 months.

Pre-operative and post operative photographic evaluation was done to assess the severity and type of caudal deviation preoperatively and post operative results and outcomes.

118 (95.2%) of 124 patients preoperatively had complaints of nasal obstruction and 6 (4.8%) patient have purely cosmetic problem. Patients having both functional and aesthetic problem are 80 (64.5%).

Visual analogue scale, photographic evaluation and subjective assessment were used to evaluate post-operative outcomes and results.

Visual analogue scale showed significant improvement with a mean score of 7.83 preoperatively to 3.56 postoperatively. Subjective assessment from patients showed marked satisfaction in 96 (77.4%) patients, moderate satisfaction in 21 (16.9%) and no improvement in 7 (5.6%) patients of total 124 patients.

Photographic evaluation was done by comparing pre and post-op photographs and showed improvement in 117 patients and seven patients have no improvement post operatively, revision was done in 5 (4%) patients of 124 patients.

Discussion

Over the years, several classification of internal nasal septal deviations have been proposed. They help us in understanding anatomy, documentation of results and plan surgical strategies that need to be addressed. Grading internal septal deflections in the anterior aspect versus along the entire nasal airway are two different problems and need to be addressed separately.

Caudal septal deviations cause more cosmetic and functional problems than do other types of septal deviations. Since it is not possible to repair a caudal septal deviation via traditional septoplasty, alternate surgical techniques needed to be developed. However, the anterior septal deviation management is quite different from management of the internal deviation.

Ineffective treatment of caudal septal deviations significantly affects both the aesthetic and functional outcomes in rhinoplasty. The deviated caudal septum has a significant impact on nasal base specially the Tip position and symmetry. Treatment of caudal septum can be the most significant element in treatment of many crocked noses.

The first description of a treatment for a caudal septal deviation was Metzenbaum’s “swinging door” method in his technique the caudal septum is mobilised to midline in a swing door fashion, which was published in 1929 [1]. Later, extended spreader grafts, batten grafts, and the tongue-in-groove method (with Mustardé-type sutures) were used, often in combination with cartilage wedging, scoring, and morselizing.

Pastorek [4] described a modification of the swing door technique in which the caudal septum is flipped on the nasal spine on the opposite side which acts as a door stopper.

Freeer [5] described the technique of septoplasty preserving the l-shaped dorsal and caudal strip to avoid post-operative nasal deformities. This technique obviously does not address correction of the caudal septum. Several techniques have been described, of scoring on the concave side and to excise a small strip from the convex side have been described to correct the deviation, results of these scoring techniques depends on the secondary healing process which is unpredictable and very often under correction or overcorrection can take place. Moreover these techniques can result in weakening of septal support with subsequent nasal deformity.

Kridel [6] described the “tongue in groove” technique for the management of caudal deviations. The procedure involves placement of the caudal septum into the groove between the medial crura to hold it in place, the tongue in groove is a useful technique in a limited number of cases, specially hanging columella, but it causes stiffness of the nose and may shorten the nose.

For cases of severe caudal septal deviation, Kayabasoglu [7] developed a modified closed technique for extracorporeal septoplasty and called this type of endonasal caudal septal replacement grafting a “marionette septoplasty” because of the appearance of the sutures when the graft is fixed and the procedure’s resemblance to marionette art.

The ethmoid splints are effective in correcting septal deviation and prevent redeviation of the reconstructed septum [8].

Nasal septal bone grafts can be an effective tool in stabilizing severe cartilaginous deformities or deviations and correcting caudal septal deviation [9].

Jang [10] preserved the naturally strong junction between the maxillary crest and the septal cartilage and involved cutting the convex most part of the caudal septum and then reconnecting it with slight overlapping of the cut ends of the caudal cartilage strut and called this approach as the cutting and suture technique of the caudal L-strut.

The classification proposed by us simplifies understanding of the anatomical situation faced and proposes strategies to tackle it in a more predictable way, both in primary septoplasty or when septoplasty is done as a part of septo-rhinoplasty.

Conclusion

A novel classification of caudal septal deviation is proposed with surgical technique directed for individual deformity.

Ineffective treatment of caudal septal deviations significantly affects both the aesthetic and functional outcomes in rhinoplasty. The deviated caudal septum has a significant impact on nasal base specially the tip position and symmetry. Treatment of caudal septum can be the most significant element in treatment of many crocked noses.

We have achieved very good results which were assessed by post-operative photographs, visual analogue scale and subjective assessment.

Compliance with Ethical Standards

Conflict of Interest

All authors declare that they have no conflict of interest.

Ethical Approval

Ethical committee permission was taken.

Informed Consent

Informed consent was obtained from all individual participants included in the study.